1. 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

2. 2 2 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

3. 3 3 FACTORS THAT IMPACT MEDICAID PHARMACY 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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6. 6 6 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

7. 7 7 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.

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9. 9 9 Be Soft on People Hard on the Problem Fisher & Vry “Getting to Yes” 1981

10. 10 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

11. 11 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.

12. 12 Our Duty = The Usual Accepted Standard of Practice EVIDENCE + EXPERT CONSENSUS + ACTUAL PRACTICE DISCUSSION AND DELIBERATION

13. 13 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

14. 14 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

15. 15 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

16. 16 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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19. 19 Overview The Behavioral Pharmacy Management System (BPMS)

20. 20 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.

21. 21 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.

22. 22 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.

23. 23 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.

24. 24 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.

25. 25 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)

26. 26 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

27. 27 BPM System Components One-Time Opportunity Analysis: Reviews 3 months Retrospective Pharmacy Claims Data to determine Prescribing patterns One-Time Opportunity Analysis: Reviews 3 months Retrospective Pharmacy Claims Data to determine Prescribing patterns Full-Service, Multi-Year Pharmacy Claims Analysis With Outlier Prescriber Education and Management Full-Service, Multi-Year Pharmacy Claims Analysis With Outlier Prescriber Education and Management

28. 28 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.

29. 29 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.

30. 30 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)

31. 31 Prescriber Alert Package content  Program purpose  Specific Indicator(s) described  Patient drug history  Best Practice summary

32. 32 Prescriber Contact Strategies Educational briefs Normative report card (benchmarking) Peer-to-Peer Consultation

33. ComprehensiveNeuroScience Missouri BPMS First Year Outlier Prescriber and Patient Change

34. 34 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?

35. 35 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 % Change New Pre- scribers Flagged This Month Two or More Antipsychotics 1,4693764544%185 Three or More Atypicals 1995310653%44 Children on 3 or More BH Drugs 1,2987060146%160 Multiple Prescribers of Anxiolytics/ Sedative Hypnotics 1,124651,07796%32 Multiple Prescribers of Atypicals 1,112881,06596%8 Dose Above FDA Limits-Atypicals 3518210940%10 Dose below FDA Limits- Atypicals 3477711934%13 Switching Atypicals too quickly for drug affect 6383345371%166 Polypharmacy 4,113722,30556%309

36. 36 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 4,400442,64660%450 Three or More Atypicals 175557543%45 Children on 3 or More BH Drugs 3,000731,28943%427 Multiple Prescribers of Anxiolytics/ Sedative Hypnotics 7965876997%23 Multiple Prescribers of Atypicals 1,330731,30598%17 High Dose Usage of Atypicals 4,155661,64540%562 Low Dose Usage of Atypicals 3,937572,05652%695 Multiple Switching of Atypicals 6383345371%166 Polypharmacy 7,951575,08364%785

37. 37 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 1304 2646 (60%)

38. 38 Targeted Outliers & Their Patients: Three or More Atypicals Patients on Three or More Atypicals: 175 Patients 55 45 75 (43%) Patients No Longer on Report Patients Still Flagged on Report New Patients This Latest Month

39. 39 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

40. 40 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%

41. 41 MISSOURI DMS (MEDICAID) BEHAVIORAL HEALTH SPENDING 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

42. 42 BPMS Impact on Healthcare Utilization N = 1911 6 months pre- mailing 6 months post mailing Percent patients hospitalized 16.8%9.5% Average number hospital days 0.310.16 Total hospital days34941681 Average total costs per patient $6347$5109

43. 43 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

44. 44 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

45. 45 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

46. 46 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

47. 47 BPMS States Pending Alaska Montana New Jersey North Carolina South Carolina

48. 48 PLEASE SEE OUR WEBSITE AT www.dmh.mo.gov/MHMPP/MHMPP.htm