Newly Diagnosed Schizophrenia Patients Have Higher Inpatient Costs But Lower Drug Costs

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The study population was selected from the Truven Health MarketScan commercial claim data files between and These files contain all paid claims generated by more than 40 million commercially insured individuals annually, as well as member identification codes that allow members to be followed longitudinally over time.

This administrative claim data set contains standard codes for diagnosis, procedure, diagnosis-related group DRG , and National Drug Code NDC ; site of service information and amounts paid by commercial insurers; and cost-sharing by members. We performed 2 analyses: The study population for each analysis consisted of individuals aged 13 to 64 years who met the HEDIS claims-based identification criteria of 2 or more inpatient or outpatient claims with International Classification of Diseases, Ninth Revision ICD-9 code In both analyses, all patients were required to be continuously enrolled for the month look-back period.

For the snapshot analysis, patients were not required to be enrolled continuously during the entire index year, and each patient's cost contribution was weighted by member months of enrollment during For the longitudinal analysis, the patients were required to be continuously enrolled for 24 months after the index date ie, date of schizophrenia diagnosis.

Schizophrenia-related emergency department visits and professional fee claims were identified if an ICD-9 diagnosis code in the Psychiatric-related emergency department and professional claims were coded with an ICD-9 code of to Outpatient facility claims other than emergency department were not designated as schizophrenia or other psychiatric. The use of electroconvulsive therapy was identified by claims coded with ICD-9 procedure codes Drug use by class—including antipsychotics, antidepressants, anticonvulsants, or antianxiety—was identified using NDC code lists from the Medi-Span drug data.

To compare the costs and medical utilization of the population of patients with schizophrenia and the population of individuals without schizophrenia in the Truven Health MarketScan claims data, we demographically adjusted the nonschizophrenic population to contribute the same weighting by 5-year age and sex bands. Of the patients with schizophrenia, The prevalence of schizophrenia was 0. The incidence of patients with schizophrenia and with no schizophrenia claims in the 12 months before the index date was 0.

Figure 1 and Figure 2 outline the prevalence and incidence of schizophrenia, by age and by sex. The annual inpatient admission rate during the study period was 13 times higher in the population with schizophrenia than in the general population, with an annual rate of admissions per patients with schizophrenia compared with an annual rate of 48 admissions per persons in the general demographically adjusted commercial population Table.

Similarly, the annual emergency department utilization rate for patients with schizophrenia was 14 times higher than in the general population— visits per patients with schizophrenia compared with visits per persons in the demographically adjusted commercial population Table.

Background

The longitudinal analysis required patients with schizophrenia to be continuously enrolled for 3 years, which allowed for a month look back from the index date and a month follow-up from the index date. Two index years were used to increase the sample size: A total of patients were identified with newly diagnosed schizophrenia. The use of antidepressants and anticonvulsants were also high: Figure 3 , Figure 4 , and Figure 5 provide details of the cost and the use of key services in the months after the index date.

Our findings corroborate the findings of previous studies in terms of schizophrenia cost and resource utilization for a commercially insured population. Data regarding the prevalence of schizophrenia in commercially insured populations are limited. Our analysis identified a lower prevalence rate of 0.

Wilson and colleagues conducted a retrospective claims analysis using a large, privately insured claims-based database in California to determine the direct costs of treating schizophrenia in a privately insured setting June May and compared the costs in newly diagnosed patients versus the costs of previously diagnosed patients. Our study shows that the reduction in costs after the index date is largely driven by a reduction in hospitalization and emergency department admission in subsequent months.

This is expected, because the diagnosis itself can be triggered by a psychotic episode, resulting in an inpatient stay. In the months after the index date, patients may receive various interventions, including medications, psychosocial therapy, family therapy, and support groups, which may contribute to the stabilization of their disease.

As a result of the very high costs associated with inpatient services, the interventions that are most effective at lowering the probability of hospital admission or readmission for patients with schizophrenia have the potential to realize the greatest cost-savings. For example, a consistent cost driver for patients with schizophrenia is suboptimal adherence to antipsychotic therapy through its association with an increased risk for relapse and rehospitalization, as well as increased hospitalization costs.

Sun and colleagues used data from 7 published articles on the economic impact of antipsychotic nonadherence among Medicaid patients with schizophrenia to estimate the costs of rehospitalization. Marcus and Olfson analyzed the correlation between gaps in antipsychotic medication and hospital admission in patients with schizophrenia based on Medicaid data — The investigators determined that improving adherence to antipsychotic medication could reduce the number of acute care admissions by approximately Our analysis provides data regarding the prevalence of schizophrenia in a commercially insured population using recent data, as well as new HEDIS claims-based identification criteria, which has not been presented previously.

In addition, more recent estimates of annual costs incurred by commercial payers across the populations of patients with newly diagnosed and chronic schizophrenia are provided, as well as a longitudinal view of resource utilization and costs during the first 2 years after diagnosis, showing that patients with schizophrenia represent a high-cost population for commercial payers. Our analysis was based on Truven Health MarketScan data, which we are unable to audit; however, we assumed that the data were accurate and comprehensive.

Claims data limitations include the potential for provider coding inaccuracies, as well as the inability to identify clinical or psychosocial factors that may impact the mix of individual patient severity levels. We recognize that individuals conducting a similar analysis using other data sets or alternative coding logic would potentially produce results that are different from ours.

Because we limited the longitudinal analysis to patients with 3 years of continuous eligibility and enrollment, we excluded individuals for whom the primary insurer changes insurers MarketScan has consistent member identification numbers for individuals enrolled in the same plan annually , and we excluded patients with schizophrenia who lost insurance, such as those who were covered by their parents and reached the age of 26 years. These patients might have purchased a separate insurance policy or might have qualified for Medicaid, which we could not distinguish and, as such, the resource utilization patterns and costs for these patients are not reflected in this study.

Schizophrenia is a debilitating disease associated with substantial medical, social, and economic burdens. The addition of several schizophrenia HEDIS criteria will most likely bring increased attention from insurers to the population of patients with schizophrenia.

Although the costs peak in the month of diagnosis, the average monthly costs remain disproportionately high throughout the month follow-up period. Further claims data analyses that investigate patterns of care, drug therapy adherence patterns, and barriers to medication adherence among patients with schizophrenia are necessary to improve the quality of care for patients with schizophrenia and to more efficiently manage the cost of the care. Schizophrenia, the forgotten illness? That may be too dramatic a description of the disease, but it nevertheless brings to light the lack of focus on schizophrenia as a disease that is rapidly growing in treatment costs, and the impact that it will have on commercial payers in the United States over the next decade.

Schizophrenia is an important disease state that will become even more important to commercial insurers as a result of the healthcare coverage expansion beginning in The cost burden of the disease state is underestimated: The article by Fitch and colleagues provides an excellent overview of the costs resulting from a diagnosis of schizophrenia, and it details how costs change over time after the index diagnosis.

Of particular interest is that the mean per-patient per-month PPPM cost for a patient with schizophrenia was more than 4 times greater than the PPPM cost for a demographically adjusted population without schizophrenia. What can we do about the costs of treating patients with schizophrenia? We do not have to look far to find meaningful ways to address schizophrenia costs, while also improving patient care.

The answer can be found with appropriate medication therapy, focusing on medications with improved effectiveness and a lower incidence of side effects, and on improving medication adherence. Although medication costs would increase by choosing newer therapies and improving adherence, studies have shown that improving medication adherence can result in lower medical expenditures overall. The latest therapies to be approved for use in the United States include oral medications with significantly less impact on exacerbating negative symptoms eg, social withdrawal, lack of motivation, etc.

Schizophrenia Costs for Newly Diagnosed Versus Previously Diagnosed Patients

Newer therapies have also been introduced in depot formulations, which provide longer periods of controlling schizophrenia with only once-monthly dosing. Although the newer medications are more expensive overall for payers, the impact on medical expenditure reductions should not be overlooked. If you believe that schizophrenia is the forgotten illness, you need not wait any longer, because the changes occurring in healthcare today, as they relate to schizophrenia, will bring this illness to the forefront for all payers. Understanding the costs and utilization associated with schizophrenia is the first step, but we need to focus next on providing cost-effective care for patients in need.

This research was funded by Genentech, Inc. Ms Fitch provides consulting services to Genentech; Mr Iwasaki is an employee of Milliman, which provides consulting services to Genentech; and Ms Villa was an employee of and had stocks in Genentech at the time of writing. National Center for Biotechnology Information , U. Am Health Drug Benefits.

Find articles by Kathleen F. This article has been cited by other articles in PMC. There was no significant difference between newly and previously diagnosed patients for each parameter in the regression. In addition, we used data from , when the use of atypical antipsychotics and mood stabilizers was more widespread, while Wu et al used data. The use of atypical antipsychotics has been demonstrated to be associated with lower hospitalization costs; unlike the Wu et al study, our results reflect this.

For our study, we feel that our total and schizophrenia-specific costs are best viewed as a maximum and minimum range of the true costs of schizophrenia.

For this diagnosis in particular, it may be common for a hospital admission or a physician visit to be attributed to a nonschizophrenia ICDCM diagnosis, despite actually being closely related to schizophrenia. Therefore, schizophrenia costs are best viewed as falling within a range of schizophrenia-specific and total costs, as we present here. A comparison of the costs between newly and previously diagnosed patients demonstrated an increase in treatment complexity for patients over time.

For example, previously diagnosed patients utilized more types of medications. Furthermore, newly diagnosed patients had 4. The lower medication use and costs in the newly diagnosed patients were likely partly due to a lack of patient compliance with schizophrenia medications, which indicates the importance of focusing on compliance in newly diagnosed patients.

The previously diagnosed patients had lower total costs and schizophrenia-related costs than the newly diagnosed patients despite the higher prescription drug costs. This higher drug cost in previously diagnosed patients is associated with much lower inpatient costs by almost half for both total and schizophrenia-related costs. These lower hospital costs may be due to a more complex medication regimen in previously diagnosed patients, with greater use of atypical antipsychotics including clozapine as well as the use of typical antipsychotics, a drug class reserved as secondary treatment after failure with initial medication therapies.

We also showed more costly medication use in the previously diagnosed patients, indicating that newly diagnosed patients were not compliant or were not being prescribed antipsychotic treatment as consistently as in previously diagnosed patients. The significantly higher medication cost for previously diagnosed patients also reflects treatment with combination therapy rather than monotherapy and is associated with lower hospital costs.

This study has all the limitations inherent in the use of retrospective claims data analyses. Paid costs were used as the proxy for economic costs to society but may not represent true opportunity costs, and we did not control for comorbidities. Costs for publicly insured patients are likely significantly higher since this population includes the jobless, homeless, and others who are more severely ill.

Our sample size is relatively small because of our strict inclusion criteria. Earlier analysis with more generous inclusion criteria gave similar results, but we were unsure whether we had true schizophrenia patients and those who were truly newly diagnosed. Therefore, we chose to select strict inclusion criteria, resulting in a smaller sample size but one that was better defined for this analysis.

Finally our sample was from to , and so did not include some of the newer long-acting atypical antipsychotics or intramuscularinjectables, which just recently were approved. The cost difference we found for newly versus previously diagnosed patients indicates that more of an emphasis should be placed on stabilizing treatment and ensuring compliance in newly diagnosed patients. The higher cost of drug treatment and the lower cost of inpatient services in previously diagnosed patients signify that this group of patients may be appropriately receiving combination treatment regimens, are more in control of their condition, and are more stable.

A detailed examination of medication costs indicates that most newly diagnosed patients are appropriately being prescribed atypical antipsychotics, with more frequent use of last-line therapies in previously diagnosed patients. This study continues to demonstrate the high cost burden of treating schizophrenia even in a privately insured population. The costs of incident or newly diagnosed cases were found to be lower than the costs of prevalent or previously diagnosed cases, which can be used by managed care to better predict total direct schizophrenia costs.

This work was partially supported by an unrestricted grant from Abbott Pharmaceuticals. Dr Wilson reports receiving grants from Novartis. An economic evaluation of schizophrenia— Soc Psychiatry Psychiatr Epidemiol.

Resource Utilization and Cost in a Commercially Insured Population with Schizophrenia

Rupp A, Keith SJ. The costs of schizophrenia: Psychiatry Clin North Am. The economic burden of schizophrenia in the United States in Annual health outcomes and treatment costs for schizophrenia populations. Healthcare spending among community-dwelling adults with schizophrenia. Am J Manag Care. The Texas medication algorithm project: Accessed February 21, Use of mood stabilizers among patients with schizophrenia, Methods for analyzing health care utilization and costs.

Annu Rev Public Health. Hospitalization and total medical costs for privately insured persons with schizophrenia. Adm Policy Ment Health. Q Rev Econ Finance. Basan A, Leucht S. Valproate for schizophrenia [update in: Cochrane Database Syst Rev. The impact on schizophrenia-related hospital utilization and costs of switching to longacting risperidone injections in Sweden. Eur J Health Econ. Accessed March 16, Benefits of Morphine for Myocardial Infarction Treatment.

Four Times a Day, Really? Importance of Medication Reconciliation in the Continuum of Care. Growth Hormone Therapy Guidelines: Clinical and Managed Care Perspectives.

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