The Missouri DMH/DMS Partnership Projects:

Improving Behavioral Pharmacy Prescribing and Utilization

and Medication Risk Management:

A MH Disease Management Strategy

NAMI Annual Convention

Austin, Texas

JUNE 20, 2005

22

Missouri Medicaid Pharmacy

Psychotropic medication accounts for over one third of total cost

Top 3 medications are antipsychotics and account for over 11% of total program cost

13 of top 25 medications by total cost are psychotropics

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FACTORS THAT IMPACT MEDICAIDPHARMACY COSTS

Factors beyond the control of State Medicaid Agencies:Medicaid membership changes;

New products;

Product Inflation (same drug, year over year)

Factors Medicaid/MH agencies can impact:Product Utilization; and

Quality of BH prescribing practice

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The National Perspective

“Drug therapies are replacing a lot of medicines as we used to know it.”

George W. Bush

October 17, 2000

Comments from St. Louis, Missouri

Presidential Debate

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Who Will Make The Choice Individual Physicians

Professional Groups

Governmental Agencies

Private Sector Contractors

Legislators

Voters

If you don’t want to choose you have no cause to complain when someone else does.

88

99

Be Soft on People

Hard on the Problem

Fisher & Vry “Getting to Yes” 1981

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Strategy for Success – The “Win / Win” Opportunity

Solve someone else’s problem and they will solve yours

Physicians – become more cost conscious

Medicaid – pursue clinical quality

PhRMA – combat inappropriate use

Dept of Mental Health – help Medicaid manage utilization and preserve access

Advocates – work together to identify acceptable limits and interventions

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Pharmacy Management “Guiding Principles”

Manage through data, not intuition or anecdote.

Monitor for both planned and unplanned consequences.

Focus management interventions on good evidence, quality treatment guidelines and compliance with medication plans.

Don’t establish the primary goal as “cost savings”. Allow cost savings to be the natural result of evidence based care, quality and adherence to treatment guidelines;

Don’t discriminate between physical and behavioral drugs, i.e. don’t limit behavioral drugs more than you would physical drugs.

Don’t punish the many, for the sins of the few. Target your Interventions to outliers who need it, not to compliers who don’t.

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Our Duty = The Usual Accepted Standard of Practice

EVIDENCE

+

EXPERT CONSENSUS

+

ACTUAL PRACTICE

DISCUSSION AND DELIBERATION

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Behavioral Pharmacy Management Services & Medication Risk Management Disease Management

Programs

Two New Approaches

Appropriate use of psychiatric medication (BPMS):

16 State Medicaid Authorities

Permits open access/open formulary

Clarifies best practice

Schizophrenia and Co-Morbidities (MRM for Schizophrenia):

Starts in ‘04

Bridges disease states

Links medical, psychiatric and community providers

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Public-Private Partnership “Dos”

Medicaid

Operates an efficient medical benefit based on evidence, quality and outcomes

DMH

Provides clinical standards and clinical expertise

CNS

Proposes new approaches and provides analytical support

PhRMA (Eli Lilly and Company)

Funds CNS projects

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Public Private Partnership “Don’ts”

Medicaid and DMH

No commitment to never use a “hard” PA

Doesn’t accept or receive PhRMA funding for projects

CNS

Shares data only with DMH and Medicaid

PhRMA

Does not control focus of projects or content of material

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New Strategies for Behavioral Health

Underlying Principles for Both Approaches:

Use of existing data sets

Supportive of existing providers

Continuous Quality Improvement Approach

Maintains Physician/Patient Autonomy

Minimizes unintended consequences

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Overview

The Behavioral Pharmacy

Management System (BPMS)

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BPMS ASSUMPTIONS

Prescribing within quality standards results in better patient outcomes at lower cost:

Better consumer (patient) adherence to medication plans;

Reduced urgent care/emergency room visits & inpatient days;

Most physicians will voluntarily prescribe within quality standards when they know what they are.

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WHAT BPMS DOES

Reviews Medicaid claims related to 130 + Medicaid behavioral drugs and reports across 4 recipient age bands regarding:

Trends in overall utilization and costs by drug class; and

Claims that deviate from quality standards.

Engages Targeted Outlier Prescribers through:

Educational messages;

Benchmarking prescribing patterns against peers; &

Peer-to-Peer consultation using noted in-state physicians.

Alerts all prescribers to patients who:

Fail to refill antipsychotic prescriptions in timely fashion; and

Are prescribed same-class BH drugs by multiple prescribers.

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BPMS MESSAGE TO PRESCRIBERS

In communicating with Prescribers, BPMS makes no recommendations regarding specific Products (Blind to Brand).

The BPMS message asks the Prescriber to voluntarily consider his/her prescriptions for specific patients during a specified timeframe.

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DEFINITIONS

Quality Indicator: A screening tool that identifies potential prescribing problems and permits focused messages to a limited number of prescribers.

Outlier Claims: Claims flagged by a quality indicator.

Outliers: Prescribers whose prescribing practice, or the patients they treat, are identified as writing/filling prescriptions in a way that falls outside the realm of “best practice” standards.

Best Practice Standards: Evidenced-based or “Consensus-based” standards (such as T-MAP or CNS guidelines).

Targeted Outliers: Top-ranked Outlier prescribers whose prescribing patterns often account for 50% or more of all claims deviating from quality standards.

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COMMON CHARACTERISTICS OF GOOD QUALITY INDICATORS

Involve health and safety issues and/or significant cost

Identify a small proportion of providers who are responsible for a large proportion of suspected errors; and

Offer empirical or national expert consensus standards for the recommended practice.

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SAMPLE OF BPM QUALITY INDICATOR CATEGORIES

Therapeutic duplication of antipsychotic drugs

Excess or Inadequate dosing of atypical antipsychotic drugs

Children concurrently receiving 3 or more behavioral health drugs

Use of two or more drugs from the same chemical class

Multiple concurrent prescribers of same class drugs

Excessive Switching of atypical antipsychotic drugs

Patient failure to refill critical therapeutic prescriptions in timely fashion (Discontinuance)

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Targeted Interventions

High Cost Prescribers With Quality Deviation:

Less than 10% of prescribers = more than 50% of cost

Missouri 300 of 11,000 physicians = 53%

AmeriChoice 100 of 2,400 physicians = 51%

Multiple Monthly Interventions: Quality letters

Outlier report

Patient drug history

Educational briefs

Peer-to-peer consultations

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BPM System Components

One-Time Opportunity Analysis:

Reviews 3 months Retrospective PharmacyClaims Data to determine

Prescribing patterns

One-Time Opportunity Analysis:

Reviews 3 months Retrospective PharmacyClaims Data to determine

Prescribing patterns

Full-Service, Full-Service, Multi-Year Pharmacy Claims Multi-Year Pharmacy Claims

Analysis With Outlier Prescriber Analysis With Outlier Prescriber Education and ManagementEducation and Management

Full-Service, Full-Service, Multi-Year Pharmacy Claims Multi-Year Pharmacy Claims

Analysis With Outlier Prescriber Analysis With Outlier Prescriber Education and ManagementEducation and Management

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BPMS DATA FLOW PROCESS Standard State Medicaid data files sent monthly to CNS :

Pharmacy claims;

Provider file with Prescriber Ids and addresses; and

Monthly Medicaid membership report

All data transferred and processed under HIPAA Guidelines.

BPMS program algorithms applied and monthly reports sent to State officials within 10-20 business days.

State approves Quality Indicator areas for education messages.

Educational alerts sent on State letterhead, under signature of State clinical leader (Prescriber Package) mailed by CNS.

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BPMS PRESCRIBER FEEDBACK PROCESS

Prescribers can provide feedback through a fax back form.

Prescribers can alert CNS to claims problems/coding errors:

“Not my Patient”

“I didn’t write this script”

BPMS often identifies state Medicaid systems problems related to claims and prescriber ID inaccuracies.

Prescribers can offer clinical comments or request peer consultation.

CNS organizes prescriber feedback by claims problems or clinical comments to send to the appropriate State Authority.

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MONTHLY CNS REPORTS RECEIVED BY BPMS STATES

Behavioral Pharmacy Summary Report

Outlier Prescriber Summary Report

Number of Patients on Concurrent Drugs Report

Quarterly Targeted Outlier Prescriber and Patient Change Report (after first four mailings)

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Prescriber Alert Package content

Program purpose

Specific Indicator(s) described

Patient drug history

Best Practice summary

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Prescriber Contact Strategies

Educational briefs

Normative report card (benchmarking)

Peer-to-Peer Consultation

ComprehensiveComprehensive NeuroScienceNeuroScience

Missouri BPMS First Year

Outlier Prescriber and Patient Change

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Key Project Outcome Questions

To what extent did “Targeted Prescribers” change their behaviors?

What happened to Targeted Prescribers’ Patients?

Were patient adherence and multiple prescriber problems reduced?

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Missouri Prescriber Change Report: June ‘03-January ‘04

Quality Indicator

# Pre-scribers Flagged During Period

Ave. Days

Flagged on

Report

# no longer

Flagged on

report

% Chang

e

New Pre-scribers Flagged

This Month

Two or More Antipsychotics 1,469 37 645 44% 185

Three or More Atypicals 199 53 106 53% 44

Children on 3 or More BH Drugs

1,298 70 601 46% 160

Multiple Prescribers of Anxiolytics/ Sedative Hypnotics 1,124 65 1,077 96% 32

Multiple Prescribers of Atypicals 1,112 88 1,065 96% 8

Dose Above FDA Limits-Atypicals

351 82 109 40% 10

Dose below FDA Limits- Atypicals

347 77 119 34% 13

Switching Atypicals too quickly for drug affect

638 33 453 71% 166

Polypharmacy 4,113 72 2,305 56% 309

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Missouri Patient Change Report: June ‘03-January ‘04

Quality Indicator

Patients Flagged by Rept. During Period

Ave. Days

Flagged on

Report

# no longer Flagged on

report

% Change

New Patients Flagged

This Month

Two or More Antipsychotics 4,400 44 2,646 60% 450

Three or More Atypicals 175 55 75 43% 45

Children on 3 or More BH Drugs

3,000 73 1,289 43% 427

Multiple Prescribers of Anxiolytics/ Sedative Hypnotics 796 58 769 97% 23

Multiple Prescribers of Atypicals 1,330 73 1,305 98% 17

High Dose Usage of Atypicals

4,155 66 1,645 40% 562

Low Dose Usage of Atypicals 3,937 57 2,056 52% 695

Multiple Switching of Atypicals

638 33 453 71% 166

Polypharmacy 7,951 57 5,083 64% 785

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Targeted Outliers & Their Patients: Two or More Antipsychotics

Providers Prescribing Two or More Antipsychotics:

1,469 Targeted Outliers

639

645 (44%)

185

Prescribers No Longer Flagged

Prescribers Still Flagged on Report

New Prescribers Latest Month

Patients on Two or More Antipsychotics: 4,400 Patients of the

Targeted Outliers

450

Patients No Longer Flagged

Patients Still Flagged on Report

New Patients Latest Month

13042646 (60%)

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Targeted Outliers & Their Patients:Three or More Atypicals

Providers Prescribing Three or More Atypicals:

199 Targeted Outliers

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106(53%)

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Prescribers No Longer on Report

Prescribers Still on Report

New Prescribers This Latest Month

Patients on Three or More Atypicals: 175 Patients

55

4575

(43%)

Patients No Longer on Report

Patients Still Flagged on Report

New Patients This Latest Month

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Targeted Prescribers & Their Patients: 3 or more Psychotropics to Children under 18 Years Old

1298 Providers Prescribing Three or More

Psychotropics to Children Under Age 18

601 (46%)537

160

Prescribers No Longer Flagged

Prescribers Still Flagged on Report

New Prescribers Latest Month

3,000 Children Under Age 18 on Three or More Psychotropics

1289 (43%)

1284

427

Patients No Longer Flagged

Patients Still Flagged

New Patients Latest Month

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Regression to the Mean: A Minor Impact

Regression to the Mean - left to themselves, things tend to return to normal

For “top 300 prescribers” identified by the CNS program is approximately 2.7% per quarter

For all prescribers of psychotropics is 5.8%

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MISSOURI DMS (MEDICAID) BEHAVIORAL HEALTHSPENDING TRENDS*

Missouri’s Division of Medical Services (Medicaid) initiated strategies to contain the growth of Medicaid behavioral pharmacy spending in 2003-2004. BPMS was the major strategy.

DMS did not restrict access to BH drugs through prior authorization, Fail-First or other “hard edit” strategies.

Mercer assisted in an independent evaluation of the impact of DMS initiatives on Medicaid BH pharmacy cost containment.

Prior to April 2003, Missouri behavioral pharmacy spending growth rate: 2.4% per month. Since April 2003, Missouri behavioral pharmacy spending growth rate: = 1.18% per month.

DMS conservatively projected savings off trend = $7.7 million.

*Presented by Dr. George Oestreich, DMS Pharmacy Director, at SAMHSA Meeting, Oct. 6, 2004

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BPMS Impact on Healthcare UtilizationN = 1911

6 months pre-mailing

6 months post mailing

Percent patients hospitalized

16.8% 9.5%

Average number hospital days

0.31 0.16

Total hospital days 3494 1681

Average total costs per patient

$6347 $5109

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Recent Improvement

CMHC Mailing

New Edits:

Any psychotropics under 4 years old

Bipolar

Adults on over 5 psychotropics

Opiates

Listing all psychotropics on 90 day individual patient report

Unduplicating entire prescriber

Separating by specialty

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Three Keys to Success in the Missouri DMH / DMS Program

1. Emphasis on Quality Improvement with Cost Savings as a secondary result;

2. A Working Partnership between Missouri Division of Medical Services and Department of Mental Health;

3. Assuring acceptance and ownership of Project goals by the clinical, advocacy and provider communities through:

A Statewide prescriber project awareness campaign;

Appointing a Statewide Project Advisory Board consisting of key psychiatric leaders, advocates (NAMI of Missouri) and provider coalitions (CMHCs) allowing the psychiatric and provider communities to take self-regulating responsibility;

Sequencing the interventions to assure Physician understanding and support for the goals of the project; and

Personalizing letters and Educational Materials

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Continuing Challenges

Optimal frequency of mailing

Pharmacy coding errors – “not my patient”

Use of consultants

“wasn’t my choice”

Mail to each practice site vs each prescriber

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BPMS ENROLLED STATES

Alabama

Arkansas

D.C.

Delaware

Florida

Illinois

Indiana

Maine

Michigan

Missouri

Mississippi

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

South Dakota

Utah

Wisconsin

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BPMS States Pending

Alaska

Montana

New Jersey

North Carolina

South Carolina

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PLEASE SEE OUR WEBSITE AT

www.dmh.mo.gov/MHMPP/MHMPP.htm