Mental Health Medication Use in Washington

A Big UnknownA Big Unknown::Mental Health Medication in WA Mental Health Medication in WA

Jeffery Thompson, M.D.

Chief Medical Officer

Washington State Medicaid

Community Mental Health Mtg

Yakima WA

June 14, 2008

WBHC WBHC ConferenceConference

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A Big A Big Unknown:Unknown:

Today’s agenda:Today’s agenda:

Review Medicaid “spends, trends Review Medicaid “spends, trends and use” of mental health and use” of mental health medicationmedication

Discuss local and national Discuss local and national variations in clinical practicesvariations in clinical practices

Discuss what happens when we Discuss what happens when we work together and link data and work together and link data and programsprograms


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

Healthy Options clients are children, TANF (*) families or pregnant women

* Note: TANF – Temporary Assistance for Needy Families

RegionSupportNetworks


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Why the Concern?Why the Concern?

Accuracy Diagnoses Accuracy Diagnoses – ( How and who?) ( How and who?)

Mental health drug poly-pharmacy & poly-Mental health drug poly-pharmacy & poly-prescribing prescribing

– (Why are these clients more @ risk?)(Why are these clients more @ risk?)

Adherence Adherence – ( Are the clients taking their meds? )( Are the clients taking their meds? )

Regional variations Regional variations – ( Can we find “best practices”?)( Can we find “best practices”?)

What about the Highest Risk?What about the Highest Risk?– (foster care, homeless, substance abuse) (foster care, homeless, substance abuse)

Coordination and information sharing with Coordination and information sharing with the provider the provider

– ( What information do you need? )( What information do you need? )

Dosing over safety thresholds Dosing over safety thresholds – ( Should there be limits?) ( Should there be limits?)


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What’s in the What’s in the News?News?


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Groundbreaking new study finds over-diagnosis of bipolar disorder

The indications and “off label” use of AAP are rapidly changing and confusing for the prescriber


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CONCLUSIONS: Current prior-authorizations policies for AAPs do not appear to reduce pharmacy reimbursement -- probably because alternative medications are costly .


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Are There Conflicts of Interest?Are There Conflicts of Interest?

Sen. Grassley Issues Report on Conflict-of-Interest Probe Into Improper Payment Disclosures by Three Harvard Psychiatrists Three well-known psychiatric researchers from Harvard Medical School may have violated federal and educational institution regulations by failing to properly disclose drug industry payments and other conflicts of interest, according to an investigation report published last week by Sen. Chuck Grassley (R-Iowa) in the Congressional Record, the Wall Street Journal reports (Armstrong, Wall Street Journal, 6/9). According to the New York Times, the group's "consulting arrangements with drug makers were already controversial because of the researchers' advocacy of unapproved uses of psychiatric medicines in children" (Harris/Carey, New York Times, 6/8).


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What’s in the What’s in the data?data?


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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

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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What about Poly-Pharmacy & AAP?What about Poly-Pharmacy & AAP?

Zyprexa

0

20

40

60

Daily Dose 40 0 40 40 40 0 15 0 0 0 0 0

J an- Feb- Mar- Apr- May- J un- J ul- 05 Aug- Sep- Oct- Nov- Dec-

Zyprexa Zydis

0

20

40

60

Daily Dose 0 0 0 0 40 20 15 20 20 0 0 0

J an- Feb- Mar- Apr- May- J un- J ul- Aug- Sep- Oct- Nov- Dec-

C lo z a p in e

0

2 0 0

4 0 0

6 0 0

8 0 0

D a i l y D o s e 5 0 0 6 0 0 6 5 0 6 0 0 6 0 0 6 0 0 6 0 0 5 2 0 0 0 0 0

J a n - F e b - M a r - A p r - M a y - J u n - J u l - A u g - S e p - O c t - N o v - D e c -

Risperdal

0

1

2

3

Daily Dose 0 0 2 0 0 0 0 0 0 0 0 0


Seroquel

0

200

400

600

Daily Dose 0 0 0 0 0 0 0 0 0 0 0 450


1

2

3

4

5

One client prescribed 5 AAPs by 5 prescribers in 12 months


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What About Regional Variation in What About Regional Variation in Washington?Washington?Map shows excessive AAP dosing (Map shows excessive AAP dosing (**) in CY 2007 among children (under 18 years old) ) in CY 2007 among children (under 18 years old)

* NOTE: Based on dosing thresholds in Texas Foster Care Step Therapy Guidelines


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What About “Off Label” Use of AAPsWhat About “Off Label” Use of AAPs Data in Dementia Is there high dosing, poly-pharmacy and poly-prescribing inData in Dementia Is there high dosing, poly-pharmacy and poly-prescribing in Dementia?Dementia?

8,726 clients over 60 years old are on Atypicals8,726 clients over 60 years old are on Atypicals..

• 2,161 or about 25% of these clients show Dementia 2,161 or about 25% of these clients show Dementia Dxs.Dxs. (not necessarily exclusive of other Dxs.)(not necessarily exclusive of other Dxs.)

• 205 of those clients with a Dementia Dx, exceed 1.5 x 205 of those clients with a Dementia Dx, exceed 1.5 x the highest study doses.the highest study doses.

AAP Drug Highest Study Dose

x 1.5 Dose

Olanzepine 15 mg 22.5 mg

Risperidone 2 mg 3 mg

Quetiapine 200 mg 300 mg

Aripiprazole 15 mg 22.5 mg

Ziprasidone 160 240 mg

Number of Clients using:1 AAP = 1322 AAP = 613 AAP = 114 AAP = 1

Number of Doctor’s Prescribing:

1 AAP = 119

2 AAP = 56

3 AAP = 21

4 AAP = 6

5 AAP = 3


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What does What does data say data say

across our across our smokestacks?smokestacks?


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Opiate Treatment SavingsOpiate Treatment Savings

What about ER Use, Pain Meds and Mental Health?

INCLUDES persons who are Medicaid-only aged, blind, disabled, presumptively disabled, or General Assistance-Unemployable in Fiscal Year 2002. SOURCE = Medicaid Integration Project database. TOTAL CLIENTS (FY 2002) = 130,274.

1 . 63 . 1 4 . 0

6 . 1

9 . 9

1 5 . 9

2 4 . 6

4 2 . 0

N o V i s i t s O n e T w o 3 t o 5 6 t o 1 0 1 1 t o 2 0 2 1 t o 3 0 3 1 +

Average Number of Narcotic Analgesic Prescriptions Per Client in FY 2002

Percent Who Received Prescriptions for PainAmong clients in FY 2002 that had. . . NO Emergency Visit ONE Visit 31+ Visits

Yes 27% Yes

51% Yes 99%

No 73%

No 49%

Number of Visits to the ER, FY 2002

n = 81,980 n = 19,393 n = 10,765 n = 11,474 n = 4,526 n = 1,607 n = 331 n = 198

Average Number of Pain Prescriptions is Highest Among Those Most Frequently Visiting the ER

89% with co-occurring


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What are the most dangerous drugs?What are the most dangerous drugs?

Moore, et al. Serious Adverse Drug Events Reported to the Food and Drug Administration, 1998-2005 - Arch Intern Med. 2007;167(16):1752-1759


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What about Medicaid Narcotic Deaths and What about Medicaid Narcotic Deaths and Mental Health?Mental Health?DOH Death Certificate CauseDOH Death Certificate Cause

•DOH 2004-2006 DOH data matched with Medicaid clients with

narcotic prescriptions in the last 3 months of life

86

39

55

138

63

71

151

79

66

0

50

100

150

200

250

300

2004 2005 2006

Medicaid Matched Possible

Medicaid Matched Probable

Medicaid Matched Definite

42% of WA Rx Deaths


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Who are those dying?Who are those dying?Washington State, 2004 – 6 (narcotic related deaths in Medicaid – linking Washington State, 2004 – 6 (narcotic related deaths in Medicaid – linking 357 death certificates to claims data)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

So what So what works???works???

Working Working together together works!!!works!!!


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Percent in DASA TreatmentMedicaid-Only Subset

Per member per month, 2 month moving average

0%

2%

4%

6%

8%

10%

12%

14%-8 -6 -4 -2 0 2 4 6 8

10

12

14

16

18

20

22

24

26

28

30

Identification Period I ntervention Period

Top 320 Group

Comparison

What Happens when DSHS Shares Information with Providers?12 month prescription history shared for Clients with > 10 narcotic Rx/month

25% reduction in Narcotics, ER is reduced, Hospitalization reducedAnd cost reduced – when information is shared


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What Happens When Data Crosses What Happens When Data Crosses Contractors?Contractors? Large differences between counties re-hospitalizations compared to Gap in AAP Large differences between counties re-hospitalizations compared to Gap in AAP therapy by Mental Health Contractors: How can we learn to use data?therapy by Mental Health Contractors: How can we learn to use data?

* 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


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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

•But there was 150% increase in Focolin

What Happens when DSHS & Providers Agree on Safety Edits?


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How do we work together?

The PDL list and OHSU reviewsRx.wa.gov

Getting a 12 month history of Rx, ER and serviceshttp://fortress.wa.gov/dshs/maa/pharmacy/Toolkit.htm

Patient Review & Coordination Program http://fortress.wa.gov/dshs/maa/PRR/

Getting a DASA services (1-800-562-1240 )http://www.dshs.wa.gov/dasa/services/treatment/treatmentexpansion.shtml

Opioid Dosing Guideline for Chronic Pain http://www.agencymeddirectors.wa.gov/opioiddosing.asp

QUESTIONS!

Mental Health Medication Use in Washington

Technology

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