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Agency for Health Care Administration (AHCA), Medicaid, Providers, Service utilization, Children, Adults, Program evaluation, Data collection, Data analysis, Health Maintenance Organizations, Medicaid Managed Care, MediPass, Penetration, Services research, Serious mental illness, Atypical anti-psychotic (AAP) medication, Cost analysis, Cost of care


Executive summaryBackground--Methods and population characteristics--Subject selection--Assignment to diagnostic groups--Standard Cost Rates--Pharmaceutical Definitions--Limitations--Results--Prevalence SMI diagnostic categories (as defined by community mental health and targeted case management service use) by AHCA area--Penetration of recommended drug classes for specific diagnostic groups--Penetration of anti-psychotics in adult schizophrenia diagnostic group--Penetration of anti-depressants in adult major depression diagnostic group--Penetration of preferred medications in target child/Adolescent diagnostic groups--Standard cost rates for all drug classes for each diagnostic group--Formulary analysis--Conclusions--References--Appendix 1: Description of problems with the statewide HMO pharmacy files--Appendix 2: Brief report of the Statewide Penetration and Standard Cost of Psychotropic Medications Study: A sub-study of the Agency for Health Care Administration (AHCA) project.


This study examined differences in pharmaceutical utilization rates relative to financial risk arrangements of differing insurance plans. There are consistent differences in the utilization of expensive, psychotropic medications between individuals enrolled in Health Maintenance Organizations (HMOs), which are at financial risk for the provision of pharmaceuticals, and the MediPass program in which the state bears the risk of pharmacy expenses. In this study these analyses are expanded to include a broader range of pharmaceutical agents than were considered earlier and a broader range of diagnostic groups, including the addition of children. After defining diagnostically homogeneous groups the annual prevalence of nine mental health diagnoses, and penetration rate, the utilization rate and standard cost rates were calculated. Results indicated that prevalence of severe mental illnesses, access to, and utilization of more expensive pharmaceuticals was related to insurance plan. As with the pre-paid mental health plan evaluation, those persons who were enrolled in plans at risk for pharmacy costs (i.e., HMOs) had a lower rate of utilization of expensive drugs. Also, persons with more severe disorders were less prevalent in the HMO plans. Standard costs and utilization, for those who were given access, were lower in HMO financing plans relative to the MediPass plan for persons in the Adult Schizophrenia group who were taking atypical anti-psychotic (AAP) medication. This was not the case for other diagnostic groups and pharmaceutical categories. [Submitted to the Florida Agency for Health Care Administration as a deliverable under contract #M030]