Real-World Cost-Effectiveness Analysis of Newer Antidepressants in Black Medicaid Beneficiaries: Evidence-Based Policy Reform to Address Treatment Disparities
Author(s)
Marie Wu, Master of Health Sciences.
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
OBJECTIVES: Johns Hopkins Medicine (JHM) identified significant treatment gaps in major depressive disorder (MDD) management among Black residents in underresourced Baltimore communities. Restrictive prior authorization policies in Maryland Medicaid limited Black patients' access to newer antidepressants with improved tolerability profiles, contributing to treatment disparities in major depressive disorder. This study evaluated the clinical and economic impact of evidence-based formulary policy changes to address these disparities.
METHODS: We conducted a retrospective cohort study using electronic health records from 8,200 Black patients with MDD (January 2019-December 2022). Propensity score matching using demographics, comorbidities, baseline depression severity, and socioeconomic indicators compared outcomes between newer antidepressants (vortioxetine, vilazodone, levomilnacipran) versus standard generic options over 24-month follow-up. Primary endpoints included medication adherence (proportion of days covered ≥80%), healthcare utilization, and total cost of care. Cost-effectiveness analysis incorporated quality-adjusted life years using EQ-5D utility weights. Model validation used bootstrap resampling with 1,000 iterations.
RESULTS: Among propensity-matched cohorts (n=4,100 each), newer antidepressants demonstrated superior medication adherence (68% vs 45%; OR 2.6, 95% CI 2.3-2.9), reduced emergency department utilization (31% decrease; IRR 0.69, 95% CI 0.62-0.77), and lower psychiatric hospitalization rates (18% decrease; IRR 0.82, 95% CI 0.71-0.95). The incremental cost-effectiveness ratio was $15,200 per quality-adjusted life year gained, with projected annual healthcare savings of $2,850 per patient. Following policy implementation, appropriate prescribing increased 340% over 18 months, generating $1.2 million in avoided acute care costs system-wide.
CONCLUSIONS: Real-world evidence demonstrating favorable cost-effectiveness of newer antidepressants enabled successful policy advocacy, resulting in modified prior authorization criteria across Maryland Medicaid managed care organizations. This approach provides a replicable framework for using HEOR evidence to address treatment disparities while achieving positive return on investment for healthcare stakeholders.
METHODS: We conducted a retrospective cohort study using electronic health records from 8,200 Black patients with MDD (January 2019-December 2022). Propensity score matching using demographics, comorbidities, baseline depression severity, and socioeconomic indicators compared outcomes between newer antidepressants (vortioxetine, vilazodone, levomilnacipran) versus standard generic options over 24-month follow-up. Primary endpoints included medication adherence (proportion of days covered ≥80%), healthcare utilization, and total cost of care. Cost-effectiveness analysis incorporated quality-adjusted life years using EQ-5D utility weights. Model validation used bootstrap resampling with 1,000 iterations.
RESULTS: Among propensity-matched cohorts (n=4,100 each), newer antidepressants demonstrated superior medication adherence (68% vs 45%; OR 2.6, 95% CI 2.3-2.9), reduced emergency department utilization (31% decrease; IRR 0.69, 95% CI 0.62-0.77), and lower psychiatric hospitalization rates (18% decrease; IRR 0.82, 95% CI 0.71-0.95). The incremental cost-effectiveness ratio was $15,200 per quality-adjusted life year gained, with projected annual healthcare savings of $2,850 per patient. Following policy implementation, appropriate prescribing increased 340% over 18 months, generating $1.2 million in avoided acute care costs system-wide.
CONCLUSIONS: Real-world evidence demonstrating favorable cost-effectiveness of newer antidepressants enabled successful policy advocacy, resulting in modified prior authorization criteria across Maryland Medicaid managed care organizations. This approach provides a replicable framework for using HEOR evidence to address treatment disparities while achieving positive return on investment for healthcare stakeholders.
Conference/Value in Health Info
2025-11, ISPOR Europe 2025, Glasgow, Scotland
Value in Health, Volume 28, Issue S2
Code
P13
Topic
Economic Evaluation
Topic Subcategory
Trial-Based Economic Evaluation, Value of Information
Disease
Mental Health (including addition)