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Speaker: JANE HORVATH September 11, 2014 PowerPoint Presentation
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Speaker: JANE HORVATH September 11, 2014
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  1. A Review of Behavioral Health Benefits in Newly Reformed Individual Marketplaces- Services and Drug Coverage Sponsored by Produced by Section I A comparison of behavioral and physical health benefits as well as provider networks in Bronze and Silver plans in five states. Section II An analysis of drug coverage, utilization management, and cost-sharing for 25 products in nine states. Speaker: JANE HORVATH September 11, 2014

  2. Mental Health America and Takeda-Lundbeck commissioned comparative research of Bronze and Silver level individual market Exchange plans in nine MHA- priority states (AZ, CA, CO, IL, MD, MT, NJ, NY, TX). SECTION I: A comparative review of services, cost-sharing, and provider networks for behavioral and physical health in individual market Exchange plans in five of the nine priority states. SECTION II: A market scan of plan formularies to assess coverage, tier placement, utilization management, and cost-sharing trendsfor 25 antidepressants and bipolar therapies in the individual market Exchange of the nine priority states. INTRODUCTION 2

  3. BEHAVIORAL HEALTH BENEFITS AND PROVIDER NETWORKS SECTION I

  4. Cost-sharing • Office visits, inpatient, outpatient? • In-network, Out-of-network? • Is BH included in OOP Maximum? • Deductible • Separate BH? • Any services excluded? • Access • BH provider in-network? • Prior authorization or referrals required for access? SECTION I: STUDY QUESTIONS BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS 4

  5. Compared and contrasted the behavioral health and physical health benefits in two Silver and two Bronze metal level plans in the individual market in the Exchanges of the most populous regions of five MHA –priority states: AZ, IL, MT, NJ, TX.* Used publicly available documents – plan summary of benefits and coverage, plan provider search functions. When available, only used data on providers listed as accepting new patients but four plans (20%) did not have this public capacity Assumed that unless otherwise specified, an BH provider is considered a ‘specialist” in each plan and patient access requires specialist-level cost-sharing Selected oncologists as comparator group to psychiatrists after consultation with MHA. There may be duplication in provider counts because some plan search functions include each provider location as a distinct, countable provider. SECTION I: METHODOLOGY *These are all Federally-Facilitated Exchanges which keep plan information public outside of the open enrollment period. State exchanges had incomplete data available for this analysis and thus were not included in this Section. BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS 5

  6. All plans appear to technically comply with the Mental Health Parity and Addiction Equity Act All plans have equal or comparable cost sharing and utilization management requirements for physical, mental and behavioral health. There were no explicit service restrictions on behavioral health services in any plan. Behavioral health cost sharing included in the out of pocket maximum of all plans. Service Coverage Highlights: 8 plans (40%) require prior authorization or referral for specialist care 7 plans (35%) have no cost sharing for both inpatient in-network behavioral health and substance abuse services Findings: BEHAVIORAL HEALTH SERVICE ATTRIBUTES No clear distinctions in services/cost sharing between metal levels or states. BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS 6

  7. Nearly all plans included coverage for non-physician providers, such as licensed clinical social workers or licensed mental health counselors. Depending on the plan behavioral health providers may or may not include psychiatrists. Seven plans have over 350 behavioral health providers in network, while nine plans have over 100 mental health providers in-network. Six plans have fewer than 10 behavioral health providers in-network. Thirteen plans (65%) have a greater number of psychiatrists than oncologists in-network. Caveats: All plan provider network information may not be up to date; Some plans do not provide information on which providers accept new patients, and This research does not include demographic analysis that might better answer a question of network adequacy. Findings: BEHAVIORAL HEALTH PROVIDER NETWORKS This research is not sufficient to evaluate network adequacy. All these plans meet federal requirements for adequacy. BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS 7

  8. With all the caveats about data quality and sample size; Out of pocket costs appear to be equal to physical health. Issues • Is there behavioral health primary care? • Are there clinical preventive services that could be considered for first dollar coverage? Robust networks are not a guarantee of access. Did not study demographics of access: time, distance, or income. Summary: BEHAVIORAL HEALTH PROVIDER NETWORKS BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS 8

  9. COMPARING BEHAVIORAL AND PHYSICAL HEALTH BENEFITS AND PROVIDER NETWORKS > MORE PSYCHIATRISTS THAN ONCOLOGISTS = BEHAVIORAL HEALTH AND PHYSICAL HEALTH COST-SHARING IS THE SAME < LESS PSYCHIATRISTS THAN ONCOLOGISTS X NO INFORMATION * THESE NUMBERS DO NOT TAKE INTO ACCOUNT PROVIDERS LISTED AT MULTIPLE LOCATIONS. MAY OR MAY NOT INCLUDE PSYCHIATRISTS. BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS

  10. Medical Necessity- “Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” -ACA Uniform Glossary MEDICAL NECESSITY DEFINITIONS All plan summary of benefits and coverage refer to the ACA Uniform Glossary for the definition of “medical necessity” • Developed by HHS and DoL • Actual interpretation will likely develop and be refined over time with federal guidance, lawsuits, etc. • Only two plans in this study specified the need for a covered service to be medically necessary • Both are Illinois plansand the service in question was primary care BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS 10

  11. In two states, Texas and Illinois, Silver plans had higher cost sharing than Bronze plans—for both inpatient and outpatient coverage. Five plans require no cost sharing for behavioral health/substance abuse outpatient services. Four Bronze, one Silver. Seven plans require no cost sharing for behavioral health/substance abuse inpatient services. Four Bronze, three Silver. Behavioral health provider network participation seems more highly correlated to carrier/plan sponsor than metal level. Network participation information captured in this analysis reflects all the shortcomings of the carrier/plan public data. Findings: BRONZE VERSUS SILVER PLANS From a behavioral health/substance abuse standpoint, Bronze vs. Silver AV level was not indicative of less cost sharing or a stronger provider network. BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS 11

  12. FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPY COVERAGE SECTION II

  13. Reviewed 25 behavioral health drug treatment therapies for coverage in plans sold on the individual market Exchanges of nine states using publicly available summaries of benefits and coverage and drug formularies. • Plans included were selected on the basis of largest enrollment or plans in the most populous region of a state. • Where coverage varied based on dosage form or strength, Breakaway captured information on the form/strength with the least access restrictions. • All averages are simply mathematical averages, not weighted. • 72 plans (36 Bronze, 36 Silver) • 4 Bronze, 4 Silver per State • 2 HMOs, 2 PPOs per State/per metal level where possible (EPO and POS used in absence) • Products SECTION II: METHODOLOGY States Reviewed Arizona California Colorado Illinois Maryland Montana New Jersey New York Texas Abilify Brintellix Celexa Clozaril Cymbalta Efexor Fetzima Geodon Invega Latuda Lexapro Paxil Pristiq Prozac Risperdal Saphris Savella Seroquel Viibryd Zoloft Zyprexa Depakote Lamictal Lithane Tegetrol FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 13

  14. AVERAGE COVERAGE RATES WITHIN STATES The average frequency of coverage for 25 products among 8 plans in each the 9 states. All Exchange plans are required by law to have an appeals process to request a drug not listed on a plan’s preferred drug list. N= 8 plans/state FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 14

  15. AVERAGE COVERAGE RATES WITHIN STATES BY METAL LEVEL 15

  16. AVERAGE COVERAGE RATES OF BRANDED VS. GENERIC THERAPIES Includes all drugs in all plans across all 9 states. 16

  17. All drugs covered in each Metal level by at least one plan • Illinois and Texas • No Difference in Coverage Count Among Metal Levels • Illinois, Texas, Colorado, Montana, New Jersey • Greater Product Coverage in Bronze v Silver Plans • Texas, California • Greater Product Coverage in Silver v Bronze Plans • Arizona, Maryland, New York • No state had no coverage of brands in any metal level • Brintellix frequently excluded on one or both levels • Pristiq only excluded in Montana BRANDED COVERAGE FINDINGS 9 branded products Abilify Brintellix Fetzima Invega Latuda Pristiq Saphris Savella Viibryd 17

  18. TIERING “CLUSTERS” BY PLAN TYPE Count of covered products by tier across all 72 plans and across all 9 states. Drugs with high rates of coverage are placed on Tier 1 Celexa, Lithane, Risperdal, Lexapro Infrequently covered drugs, when covered, are commonly on Tier 3 Viibryd, Brintellix, Fetzima, Saphris FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 18

  19. TIERING “CLUSTERS” BY METAL LEVEL Count of covered products across all 72 plans across all 9 states Drugs with high rates of coverage are placed on Tier 1 Celexa, Lithane, Risperdal, Lexapro Infrequently covered drugs, when covered, are commonly on Tier 3 Viibryd, Brintellix, Fetzima, Saphris FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 19

  20. TIERING “CLUSTERS” BY STATE Count of covered products across all 72 plans across all 9 states FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 20

  21. OVERVIEW OF FINDINGS • Use of prescription-only deductibles in 4 states: AZ, CA, IL, MD • Lowest in CA ($250) • Varies significantly by metal level • Little variation in copays and coinsurance by metal level • High rates of utilization management, especially quantity limits FINDINGS COST SHARING FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 21

  22. AVERAGE PRESCRIPTION-ONLY DEDUCTIBLES BY STATE Only 4 states analyzed used a prescription-only deductible, with CA’s being significantly lower than the rest. The other states in the study used combined (medical+prescription) deductibles, which were not captured in this analysis. FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 22

  23. AVERAGE PRESCRIPTION-ONLY DEDUCTIBLES BY METAL LEVEL • Among the 4 states using a prescription-only deductible FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 23

  24. COST-SHARING IN PLANS WHERE RX EXEMPT FROM ANY DEDUCTIBLE BY METAL LEVEL Average copays by metal level across all states and among all plans that exempt Rx from any deductible. Only includes plans that specify a copay amount. FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 24

  25. AVERAGE COST-SHARING WHEN DRUGS APPLY TO DEDUCTIBLE BY METAL LEVEL Average cost-sharing among all plans and across all states Only includes plans that specified a cost-sharing value greater than $0 or 0% Top chart is average copaybefore any deductible is met by metal level Lower chart is average coinsurancebefore any deductible is met by metal level FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 25

  26. AVERAGE COST-SHARING WHEN DRUGS APPLY TO DEDUCTIBLE BY METAL LEVEL Average cost-sharing among all plans and across all states Only includes plans that specified a cost-sharing value Top chart is average copayafter any deductible is met by metal level Lower chart is average coinsuranceafter any deductible is met by metal level FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 26

  27. AVERAGE UTILIZATION MANAGEMENT BY PLAN TYPE Key takeaway: Slightly higher application of UM in HMO plans with a similar, though less frequent, pattern across drugs among PPO plans Branded FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES Branded Generic 23

  28. AVERAGE RATE OF UTILIZATION MANAGEMENT BY STATE AND TYPE OF UM Key takeaways: Quantity limits most common UM approach Step therapy is a significant UM approach FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 28

  29. Few differences in cost-sharing between Bronze and Silver plans Branded products covered less often and placed on Tier 3 when covered High utilization management rates, particularly for branded drugs Quantity limits used heavily in most states No readily available information to indicate disparate treatment of behavioural health/substance abuse services from physical health. KEY FORMULARY TAKEAWAYS 29

  30. A Review of Behavioral Health Benefits in Newly Reformed Individual Marketplaces- Services and Drug Coverage Sponsored by Produced by Speaker: JANE HORVATH September 11, 2014

  31. COVERAGE RATES OF EACH DRUG BY STATE APPENDIX

  32. Branded FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 32

  33. Branded FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 33

  34. Branded FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 34