Cost-per-remitter with esketamine nasal spray versus standard of care for treatment-resistant depression.

Aim: Estimate the cost-per-remitter with esketamine nasal spray plus an oral antidepressant (ESK + oral AD) versus oral AD plus nasal placebo (oral AD + PBO) among patients with treatment-resistant depression. Patients & methods: An Excel-based model was developed to estimate the cost-per-remitter for ESK + oral AD versus oral AD + PBO over 52 weeks from multiple US payer perspectives. Clinical end points and cost inputs were derived from clinical trials and the literature, respectively. Results: Under the base-case scenario, the cost-per-remitter for ESK + oral AD and oral AD + PBO were as follows: Commercial: US$85,808 versus US$100,198; Medicaid: US$76,236 versus US$96,067; Veteran's Affairs: US$77,765 versus US$104,519; and Integrated Delivery Network: US$103,924 versus US$142,766. Conclusion: The findings suggest that ESK + oral AD is a cost-efficient alternative treatment for treatment-resistant depression compared with oral AD + PBO.

Lay abstract The US FDA recently approved esketamine nasal spray plus an oral antidepressant (AD) as a new treatment for adults with treatment-resistant depression. We developed an Excel-based model to understand whether esketamine + oral AD treatment offers better value for the money spent, compared with treatment with oral AD alone. We find that the higher annual costs of esketamine + oral AD treatment are more than offset by the better clinical outcomes achieved with this treatment. Specifically, in a given year, more people treated with esketamine + oral AD versus oral AD alone achieved and remained in remission, and as a result, they incurred fewer other medical costs.

Open enrollment periods and plan choices.

Open enrollment periods are pervasively used in insurance markets to limit adverse selection risks resulting when enrollees can switch plans at will. We exploit a change in the open enrollment rules of Medicare Advantage to analyze how beneficiaries responded to the option of switching to a 5-star-rated plan at anytime, in a setting where insurers adjusted premiums and benefit design to counterbalance the increased selection risk. We present three findings: Within-year switches to 5-star plans increase by 7-16%; demand for 5-star plans across the years does not decline; and the enrollees who switch to a 5-star plan during the year are in better health status than those who do not switch.

Insurers' response to selection risk: Evidence from Medicare enrollment reforms.

Evidence on insurers' behavior in environments with both risk selection and market power is largely missing. We fill this gap by providing one of the first empirical accounts of how insurers adjust plan features when faced with potential changes in selection. Our strategy exploits a 2012 reform allowing Medicare enrollees to switch to 5-star contracts at anytime. This policy increased enrollment into 5-star contracts, but without risk selection worsening. Our findings show that this is due to 5-star plans lowering both premiums and generosity, thus becoming more appealing for most beneficiaries, but less so for those in worse health conditions.