A Big UnknownA Big Unknown:: How to How to Use Data to Improve Use Data to Improve

Policy and QualityPolicy and Quality

Jeffery Thompson, M.D.

Chief Medical Officer

Washington State Medicaid

Academy Health

Washington DC

June 8th 2008

Academy Academy HealthHealth

Washington, Washington, D.C.D.C.

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Using Using Data to Data to

Improve Improve Policy Policy

and and QualityQuality

Today’s agenda:Today’s agenda:

1. Discuss local and national variations in 1. Discuss local and national variations in Medicaid programs and Secular Trends – How Medicaid programs and Secular Trends – How to Measure the Un-measurableto Measure the Un-measurable

2. Discuss the need to go beyond claims data – 2. Discuss the need to go beyond claims data – there is a treasure chest of data but where is there is a treasure chest of data but where is the mapthe map

3. Show a picture of what happens when data 3. Show a picture of what happens when data and policy work together – Things Happenand policy work together – Things Happen

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Using Using Data to Data to

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and and QualityQuality

Washington State: FFS & managed careWashington State: FFS & managed care

When you seen one Medicaid State – You seen one Medicaid State! BS

Truth: Medicaid States have similar populations and similar service trends that in many ways are the same as commercial markets

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and and QualityQuality

Input and Outputs of Mental Health Input and Outputs of Mental Health Issues: Secular Events in and out of Issues: Secular Events in and out of Medicaid are tough to study or even Medicaid are tough to study or even know!know!                   

Utilization controlsUtilization controls Cost Saving policies, code and statutesCost Saving policies, code and statutes Continuity of Care Continuity of Care Adherence to therapiesAdherence to therapies Regional variationsRegional variations High Risk Eligibility types High Risk Eligibility types (foster care, homeless, chronic health issues)                             (foster care, homeless, chronic health issues)                             Diagnosis accuracyDiagnosis accuracy Dosing and safety thresholds   Dosing and safety thresholds    Drug and AlcoholDrug and Alcohol Criminal JusticeCriminal Justice              

Missing a secular trend often generates type 1 or 2 error.

Researchers must have closer working relations with policy and staff

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Using Using Data to Data to

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CONCLUSIONS: High expenditures on these medications are thus likely to continue without concomitant gains for public health.

The value of “on label ” and “off label” is in the eyes of the reader or disbeliever. The 900 page tech assessment is not enough!

Academy Academy HealthHealth

Washington, Washington, D.C.D.C.

June 8, 2008 June 8, 2008 66

Using Using Data to Data to

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and and QualityQuality

Anti-Psychotic drug expendituresAnti-Psychotic drug expendituresWashington State, 2000 - 2007Washington State, 2000 - 2007

The AAP class is the No. 1 expenditure for most Medicaid states. The 21% growth in AAP costs is driven by both unit cost and growth in utilization: This gets the attention of administrators

N O N D U A L A N T I -P S Y C H O T I C D R U G E X P E N D I T U R E S C Y 2000 T H R U 2007

$28,564,802.21

$35,064,257.64

$44,120,752.10

$55,001,770.91

$62,731,419.98

$67,640,672.35

$21,023,036.10

$76,526,563.34

$0

$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

$60,000,000

$70,000,000

$80,000,000

2000 2001 2002 2003 2004 2005 2006 2007

EX

PE

ND

ITU

RE

S

K I D S

A D U L T S

T O T A L

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Using Using Data to Data to

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and and QualityQuality

Regional variation in Washington:Regional variation in Washington:Large differences between countiesLarge differences between counties

Map shows excessive AAP dosing (Map shows excessive AAP dosing (**) in CY 2007 among ) in CY 2007 among children (under 18 years old) children (under 18 years old) 

Showing provider and regional variation: This gets the attention of providers

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Using Using Data to Data to

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and and QualityQuality

Mental Health Care Variation in Mental Health Care Variation in WashingtonWashington:: Large differences between counties re-Large differences between counties re-

hospitalizations compared to Gap in AAP therapy by Mental Health Contractorshospitalizations compared to Gap in AAP therapy by Mental Health Contractors

* NOTE: 9000 Clients with schizophrenia: Relationships holds for poly-pharmacy (#Rx/year) and Poly-prescriber (#Rxers/year) ER utilization and SNF care rates

-

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

0_10 11_20 21_40 40over

#admits/100

Gap days

Looking at data across systemsis more informative than by systems:The data generated a review of 2500 high costs clients and 40 record reviews

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Linking Deaths and SmokestacksLinking Deaths and SmokestacksWashington State, 2004 – 6 (narcotic related deaths in Washington State, 2004 – 6 (narcotic related deaths in Medicaid – linking 357 death certificates to claims data)Medicaid – linking 357 death certificates to claims data)

Integrating across agencies and data systems is a must because Contracts and payment systems do not treat the riskiest clients. This data has sold a narcotic review program and provider support

FREQUENCY PERCENT

Alcohol/ Drug Treatment Need Flag 152 40.5%

Mental I llness Diagnosis ProfilePsychotic Disorder 45 12.0%

Mania/Bipolar Disorder 54 14.4%Depression 105 28.0%

Dementia 7 1.9%Developmental Delay 1 0.3%

Personality Disorder 48 12.8%Adjustment/Stress Disorder 93 24.8%

Mental Health Medication ProfileSedative 152 40.5%

Antianxiety 172 45.9%Antipsychotic 114 30.4%

Antidepressant 229 61.1%ADHD 13 3.5%

Antimania 11 2.9%Anticonvulsant 176 46.9%

Narcotic Profile in 3 Months Prior to Death% with Avg Daily Morphine Equivalence >= 120 mg 83 22.1%

Mean Avg Daily Morphine Equivalence 101

TOTAL 375

DEFINITE

WA Medicaid is 42% of all narcoticrelated deaths

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DOSE, AGE and COMBIATION STOPS in DOSE, AGE and COMBIATION STOPS in ADHD Therapies: A Community Agreed ADHD Therapies: A Community Agreed Prescribing Program (WAPA, AAFP, Prescribing Program (WAPA, AAFP, WASPA, P&T/DUR)WASPA, P&T/DUR)

Age – Less than 5 years oldAge – Less than 5 years old

Dose – Dose – Amphetamines Amphetamines 60mg, 60mg, MethylphenidatesMethylphenidates 120mg 120mg

COMBINATIONS -COMBINATIONS -o Combinations of Strattera with stimulant ADHD drugs require Combinations of Strattera with stimulant ADHD drugs require

Prior Authorization; tapers are authorized for a maximum of 30 Prior Authorization; tapers are authorized for a maximum of 30 days.days.

Strattera ThresholdStrattera Threshold for 5 years and older – 120 mg per day as a for 5 years and older – 120 mg per day as a single daily dose.single daily dose.

– Allow mono-therapies with 8 weeksAllow mono-therapies with 8 weeks

Cross overCross over

– Combination therapies require Combination therapies require

Tried and failed mono-therapiesTried and failed mono-therapies

What Sells: Showing the # of 1 year olds and kids on > 3 stimulants works when EBM is not enough

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Learning and Implementing other state Learning and Implementing other state processes: processes: ADHD second opinions for stimulant prescriptions (2004-2008)

There are ~27,000 users of stimulants with 1000 ADHD Second Opinions that resulted in:

•Rxs for Children less then 5 year old 24% •Poly pharmacy use 48%•High doses of stimulants 63%•Most stimulants in utilization (-0.4 to -35%)•There are NO less than 5 year olds on high dose stimulants

What about the other outcomes (Juvenile Justice, truancy, foster care placements, graduation rates, ER etc)? We need to go beyond claims data

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Using Using Data to Data to

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Multiple state processesMultiple state processes

Which process is a “best practice” and which combinations offer the best outcomes of access, quality, safety and cost? We need more cross-state comparisons!

Second opinionsSecond opinions Tennessee, WashingtonTennessee, Washington

Preferred drug listsPreferred drug lists Illinois, FloridaIllinois, Florida

Phone-basedPhone-based West Virginia, TexasWest Virginia, Texas

ConsultationsConsultations Mississippi, WashingtonMississippi, Washington

Lilly CNS programLilly CNS program Florida, Rhode Island, OregonFlorida, Rhode Island, Oregon

Step therapies, guidelinesStep therapies, guidelines TexasTexas

Prior authorizationPrior authorization OhioOhio

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Using Using Data to Data to

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We need the policy bottom line!!!!!!!!!

can be managed with policy

Clinical algorithms that are communicated withProvider specific report cards reduce variation

Preferred drug lists can be used without decreasing clinical quality

Second opinion programs can improve safety and reduce clinical variation

Refill protections, grandfathering and dispense as written protections are good policies

There is evidence that policy programs can support and improve the clinical value of state funded AAPs in Kids:

The Lilly CNS program reduces safety related issuesIn AAP prescribing

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Questions?