Budgetary impact of the utilization of buprenorphine/naloxone sublingual film and tablet for Medicaid in the United States

Figures & data

Table 1. Scenarios 1 and 2: buprenorphine/naloxone market share breakdown.

Scenario 1	Year 1	Year 2	Year 3	Year 4	Year 5
82% Suboxone film/18% tablet
Suboxone film	81.68%	69.43%	62.49%	56.24%	50.62%
Amneal tablet	8.98%	14.98%	18.38%	21.45%	24.21%
Actavis tablet	8.98%	14.98%	18.30%	21.29%	24.02%
Mallinckrodt tablet	0.36%	0.61%	0.83%	1.02%	1.15%
Scenario 2
100% Suboxone film
Suboxone film	100.00%	100.00%	100.00%	100.00%	100.00%
Amneal tablet	0.00%	0.00%	0.00%	0.00%	0.00%
Actavis tablet	0.00%	0.00%	0.00%	0.00%	0.00%
Mallinckrodt tablet	0.00%	0.00%	0.00%	0.00%	0.00%

Figure 1. Model structure.

Figure 2. Treatment periods.

Figure 3. Tornado-Total incremental costs over 5 years.

Table 2. Average patient profile.

Patient characteristics	Means/percentages
Age (years)
Mean (SD)	33.26 (9.27)
Gender
Male	28.85%
Female	71.15%
Race
White	83.12%
Black	3.91%
Hispanic	5.99%
Other	6.98%
Daily dose at index date (mg)
Mean (SD)	15.79 (6.28)
Patients with at least one diagnosis of a mental disorder (except drug use) in the 6 months before index date
%	70.89
Patients with at least one diagnosis of chronic pain
%	15.94
Proportion of patient with at least two opioid prescriptions
%	52.29
Type of insurance plan product
Capitated	63.07%
Fee-for-service	36.93%
Mental health/substance abuse coverage
Covered	90.16%
Not covered	9.84%

Table 3. Transition probabilities.

	Film		Tablet
Input – transition probabilities	Capitation	Fee-for service	Capitation	Fee-for service
From Initiation
To Maintenance (no history of discontinuation)	100.00%	100.00%	100.00%	100.00%
From Maintenance (no history of discontinuation)
To Maintenance (no history of discontinuation)	91.77%	93.62%	90.72%	92.79%
To Discontinuation	8.23%	6.38%	9.28%	7.21%
From Discontinuation
To Off-treatment (first 6 months)	100.00%	100.00%	100.00%	100.00%
From Off-treatment (first 6 months)
To Off-treatment	92.37%	92.50%	92.13%	92.26%
To Reinitiation	7.63%	7.50%	7.87%	7.74%
From Off-treatment (following months)
To Off-treatment (following months)	99.67%	99.53%	99.72%	99.60%
To Reinitiation	0.33%	0.47%	0.28%	0.40%
From Reinitiation
To Discontinuation	18.84%	15.22%	18.22%	14.70%
To Maintenance (history of discontinuation)	81.16%	84.78%	81.78%	85.30%
From Maintenance (history of discontinuation)
To Discontinuation	18.84%	15.22%	18.22%	14.70%
To Maintenance (history of discontinuation)	81.16%	84.78%	81.78%	85.30%

The model inputs including transition probabilities, resource use, and costs were estimated from the Truven Health MarketScan Database.

Table 4. Input costs by resource utilization, state and formulation.

	Initiation		Maintenance		Discontinuation		Off-treatment		Reinitiation
	Film	Tablet	Film	Tablet	Film	Tablet	Film	Tablet	Film	Tablet
Other medication costs*	$159	$159	$207	$207	$280	$280	$199	$199	$169	$169
Outpatient care costs	$847	$847	$432	$406	$537	$537	$395	$395	$638	$638
Emergency room care costs	$97	$97	$65	$65	$104	$104	$67	$96	$67	$67
Non-psychiatric inpatient care costs	$196	$243	$83	$111	$342	$407	$187	$194	$59	$260
Psychiatric inpatient care costs	$267	$267	$31	$53	$88	$88	$67	$67	$191	$191
Buprenorphine/naloxone treatment costs	$328	$403	$395	$448	$54	$50	$0	$0	$311	$382

*All medication costs other than buprenorphine/naloxone.

The model inputs including transition probabilities, resource use, and costs were estimated from the Truven Health MarketScan Database.

Table 5. Budget impact results by resource category and over 5 years for the Medicaid population rising from 65.6 million to 76.1 million.

Scenario 1	Year 1	Year 2	Year 3	Year 4	Year 5	Total
Pharmaceutical cost	$277,788,969	$379,853,884	$ 473,733,542	$563,354,413	$650,870,288	$2,186,957,359
Buprenorphine/naloxone treatment	$165,128,349	$194,221,814	$213,702,156	$227,650,642	$238,612,156	$975,464,391
Other	$112,660,620	$185,632,070	$260,031,385	$335,703,772	$412,258,133	$1,211,492,968
Outpatient care	$252,581,182	$389,993,180	$537,595,499	$687,069,550	$838,103,730	$2,511,360,933
Emergency room care	$39,198,023	$64,836,059	$92,613,325	$121,646,532	$151,741,508	$435,586,768
Inpatient care	$107,751,535	$189,713,926	$282,857,034	$379,295,286	$477,789,879	$1,330,178,734
Psychiatric	$71,760,136	$133,538,529	$201,383,100	$271,821,212	$343,869,473	$945,510,568
Non-psychiatric	$35,991,399	$56,175,397	$81,473,934	$107,474,074	$133,920,406	$384,668,165
TOTAL	$677,319,709	$1,024,397,049	$1,386,799,399	$1,751,365,782	$2,118,505,406	$6,464,083,794
Scenario 2	Year 1	Year 2	Year 3	Year 4	Year 5	Total
Pharmaceutical cost	$274,484,170	$375,574,217	$468,370,208	$557,006,843	$643,637,316	$2,162,206,760
Buprenorphine/naloxone treatment	$161,833,338	$189,928,052	$208,298,914	$221,235,102	$231,281,925	$950,523,662
Other	$112,650,832	$185,646,165	$260,071,295	$335,771,741	$412,355,391	$1,211,683,098
Outpatient care	$256,799,099	$396,895,927	$547,160,096	$699,206,941	$852,680,838	$2,555,355,100
Emergency room care	$38,556,990	$62,407,201	$87,562,131	$113,168,721	$139,092,848	$408,829,817
Inpatient care	$103,004,323	$181,348,564	$270,731,384	$363,327,632	$457,958,489	$1,273,647,623
Psychiatric	$68,551,392	$127,747,212	$192,836,955	$260,399,991	$329,495,813	$905,400,778
Non-psychiatric	$34,452,931	$53,601,352	$77,894,429	$102,927,641	$128,462,676	$368,246,845
TOTAL	$672,844,583	$1,016,225,909	$1,373,823,820	$1,732,710,137	$2,093,369,491	$6,400,039,301
Scenario 1 − Scenario 2	Year 1	Year 2	Year 3	Year 4	Year 5	Total
Pharmaceutical cost	$3,304,799	$4,279,667	$5,363,333	$6,347,570	$7,232,973	$24,750,599
Buprenorphine/naloxone treatment	$3,295,012	$4,293,762	$5,403,243	$6,415,540	$7,330,231	$24,940,729
Other	$9787	$-14,095	$-39,910	$-67,970	$-97,258	$-190,130
Outpatient care	$-4,217,917	$-6,902,747	$-9,564,598	$-12,137,390	$-14,577,108	$-43,994,167
Emergency room care	$641,032	$2,428,859	$5,051,195	$8,477,810	$12,648,660	$26,756,951
Inpatient care	$4,747,212	$8,365,362	$12,125,650	$15,967,655	$19,831,390	$56,531,110
Psychiatric	$3,208,744	$5,791,317	$8,546,145	$11,421,222	$14,373,660	$40,109,790
Non-psychiatric	$1,538,468	$2,574,045	$3,579,505	$4,546,433	$5,457,730	$16,421,320
TOTAL	$4,475,126	$8,171,140	$12,975,580	$18,655,645	$25,135,915	$64,044,493

Table 6. Sensitivity analysis.

Total Incremental cost over 5 years	lower bound	upper bound		Base Case
Proportion capitated: 0% -- 100%	$63,607,520	$64,300,358	$692,838	$64,044,493
Cost ratio for non-psychiatric care in the maintenance state: confidence interval	$61,401,298	$66,697,981	$5,296,683
Time to reinitiation following months: confidence interval	$57,622,151	$67,045,980	$9,423,829
Time to second discontinuation: confidence interval	$70,027,280	$57,089,104	$12,938,176
Time to reinitiation first 6 months: confidence interval	$52,199,453	$73,317,012	$21,117,559
Time to first discontinuation: confidence interval	$78,418,541	$49,007,347	$29,411,194
Incidence: ± 25% of base case	$48,033,370	$80,055,617	$32,022,247
Probability of non-psychiatric hospitalization in “off treatment” state: confidence interval	$78,181,334	$32,507,405	$45,673,930
Probability of non-psychiatric hospitalization in “off treatment” state for buprenorphine/naloxone film patients only: confidence interval	$1,200,000	$103,400,000	$102,200,000
Rebate for buprenorphine/naloxone tablets: 50%		$−115,799,996	$115,799,996