Better Antipsychotic Adherence Could Save Governments Millions

The Centers for Medicare and Medicaid Services is the largest payer for mental health services in the United States, with schizophrenia-associated costs accounting for a large burden of such spending—making the disorder a major target for disease-management intervention.

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Findings from an analysis conducted by the RAND Corporation on the potential net savings to state budgets from interventions to improve adherence to antipsychotic drugs in patients with schizophrenia were published January 2 in Psychiatric Services in Advance.

“Antipsychotic medications are effective in controlling disturbing symptoms of schizophrenia, including hallucinations and paranoid delusions, and adequate adherence has been shown to reduce the risk of hospitalization, the costliest form of health care,” coauthor Soeren Mattke, M.D., M.P.H, a senior scientist at RAND, told Psychiatric News.

According to the study, schizophrenia accounts for approximately 1.5 percent to 3 percent of the total Medicaid spending for mental health care, in addition to being costly in other areas outside of direct health care. The authors cited a recent study showing that 46 percent of a sample population with schizophrenia had at least one interaction with the justice system as either a perpetrator or a victim of a crime within a given year.

“The associated costs to the states of these interactions are substantial,” the researchers noted, “as evidenced by an average annual cost of $1,881 per person [in 2013], which includes only the cost of arresting and incarcerating the perpetrators but not the cost of providing forensic inpatient care.” They added that interventions to increase adherence to antipsychotic medication in people with schizophrenia have been shown to reduce costs and improve outcomes.

In the current study, the researchers conducted a literature review to investigate schizophrenia-related financial burdens incurred by states in 2013, including direct costs for mental health care to Medicaid programs and the criminal justice system.

The analysis estimated annual schizophrenia-related spending of $21.4 billion by state Medicaid programs and criminal justice systems. The bulk of spending was attributed to direct health care costs—$16.9 billion, or 79 percent—with the remaining $4.6 billion related to spending in the criminal justice system. Of the estimated direct health care costs, psychiatric outpatient treatment accounted for 43.5 percent of the expenditures, while inpatient treatment and prescription drugs accounted, respectively, for 40.7 percent and 15.2 percent. Annual cost to state budgets ranged from $33.1 million in Idaho up to $3.29 billion in California.

Based on the financial model used, the researchers found that improvements in interventions for antipsychotic adherence would yield annual net savings up to $3.28 billion for state budgets and net savings of $1,580 per patient per year. Most of these savings would come from lower hospitalization rates and would require total expenditure for prescription drugs by states to increase by 18.3 percent.

“It’s important for legislators to understand that money can be saved to state budgets if access to antipsychotics is made less burdensome for patients,” Mattke stated. He said that interventions to increase adherence could include medication-management programs, such as counseling by pharmacists or advance-practice nurses, or cognitive adaptive training, which attempts to change patients’ behaviors by modifying their home environment through alarms, checklists, and electronic medication monitoring that remind patients to take their medications. Mattke also cited a more “straightforward” intervention—long-acting injectable antipsychotics, which help ensure patients’ adherence from 30 to 90 days, depending on the extent of a medication’s activity.

“We have to rethink the cost for better health care management of schizophrenia on the state level rather than in silos such as budgets allocated to inpatient care and outpatient [care] … and really think of the total financial burden caused by untreated schizophrenia and mental illness,” Mattke emphasized. “Hopefully, data presented in this study will create a dialogue on how we can optimize spending that will both benefit patients and state finances.” ■