MISSOURI PARTNERSHIP

MISSOURI PARTNERSHIP

Children’s Division/DSSMO HealthNet/DSS

Office of Clinical Officer/DMH

“Policy” Webster's Dictionary 1966

• “Prudence or wisdom in the management of public affairs”

• “A definite course or method of action and selected from among alternatives and in the light of given conditions to guide and determine present and future decisions”

“Policy” Thomas Fuller 1608-1661

“Policy consists in serving God in such a manner as not to offend the devil”

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Be Soft on People

Hard on the ProblemFisher & Vry “Getting to Yes” 1981

What Made it Possible? - Relationships

• Values– Stability - Transparency– Trust - Common Agenda

• Partners– The State Medicaid Authority – MO HealthNet – DMH– State Budget Office– Missouri Coalition of CMHCs – The Missouri Primary Care Association– Vendors: Xerox, CMT, WIPRO, MIMH

• Data - Use of Health Information Technology to identify and monitor problems, and assess performance

S.M.R. Covey, The Speed of TrustBehaviors that Promote Trust

• Character– Talk Straight– Demonstrate Respect– Create Transparency– Right Wrongs– Show Loyalty

• Competence– Deliver Results– Get Better– Confront Reality– Clarify Expectations– Practice Accountability

• Character & Competence• Listen First• Keep Commitments• Extend Trust

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Strategy for Success – The “Win / Win” Opportunity

Solve someone else’s problem and they will solve yours– Physicians – become more data and cost

conscious– Medicaid – pursue clinical quality– Dept of Mental Health – help Medicaid manage

utilization and preserve access– Advocates – work together to identify acceptable

limits and interventions– Vendors – combat inappropriate use

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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.

Missouri’s Behavioral Pharmacy Management

• Helps improve prescribing practices

• Identifies clinicians whose prescribing patterns deviate from current clinical best-practices

• Quality Indicators are developed from– continuous review of medical literature– consensus guidelines– nationally recognized clinical panels

The Quality Indicators™ and analytic methods presented in this document are confidential and proprietary trade secrets of Care Management Technologies (CMT). This document and its contents may not be used, disclosed, or redisclosed except with the written agreement from CMT.

Child BPM Program

• 1,367 Missouri children who triggered BPM QI’s in May 2011 and were eligible in October 2011 and April 2-12 were studied.

• From May 2011 to April 2012, behavioral pharmacy costs fell 11% for this group.

• During this time, total pharmacy costs fell 7.5%.

• Most children triggering polypharmacy QI’s in May 2011 were no longer triggering them in April 2012.


Child BPM Program

QI # May 2011

April 2012

% Change May 2011 to April 2012

101 Use of Benzodiazepines for 60 or More Days (Under 18 Years) 325 135 -58%

205 Use of 2 or More Antipsychotics for 45 or More Days (Under 18 Years) 192 76 -60%

510 Use of an Antipsychotic at a Higher Than Recommended Dose for 45 or More Days (Under 18 Years) 165 41 -75%

202 Use of 3 or More Psychotropics for 90 or More Days (6-12 Years) 103 18 -83%

505 Use of Clonidine at a Higher Than Recommended Dose for 45 or More Days (Under 18 Years) 99 38 -62%

311 Use of an Atypical Antipsychotic in a child four years old or younger 96 19 -80%

417 Multiple Prescribers of the Same Class of Psychotropic Drug for 45 or More Days (Under 18 Years) 92 26 -72%


Child BPM ProgramQI # May

2011April 2012

% Change May 2011 to April 2012

205 Use of 2 or More Antipsychotics for 45 or More Days (Under 18 Years) 192 76 -60%


106 Use of 2 or More Atypicals and a Stimulant or ADHD Non-Stimulant for 30 or More Days (Under 18 Years) 72 23 -68%


511Use of an Antipsychotic at a Higher Than Recommended Dose and a Stimulant or ADHD Non-Stimulant for 45 or More Days (Under 18 Years)

26 8 -69%

508Use of a Stimulant or ADHD Non-Stimulant AND Use of a TCA at a Higher Than Recommended Dose and for 45 or More Days (Under 18 Years)

9 2 -78%

504 Use of an ADHD Non-Stimulant at a Higher Than Recommended Dose for 45 or More Days (Under 18 Years) 6 3 -50%

160 Use of 2 or More Benzodiazepines for 45 or More Days (Under 18 Years) 1 0 -100%

167 Use of 2 or More Tricyclic Antidepressants for 60 or more days (Under 18 Years) 1 0 -100%

169 Use of 2 or More Insomnia Agents for 60 or More Days (Under 18 Years) 1 1 0%

Total (may include duplicate patients) 461 141 -69%

• Impact analysis shows $6.77 million in behavioral pharmacy cost avoidance for the 23,371 child patients continuously eligible since February 2010 who were subjects of a BPM mailing.

• This is an average of $124.42 per intervened patient per month.

• The patients were followed for an average of 17.5 months post-mailing.


Child BPM Program

Outlier Pattern 2006-2009Kids Percentage of Patients

7/09-9/09 9/09-11/09

Total Antipsychotics 25.7% 22.5%

2 Antipsychotics 2.5% 2.7%

Hi Dose Antipsychotic 1.8% 2.0%

Antipsychotics < 4 y o 1.3% 1.4%

5 or more 1.8% 1.6%

Outlier Pattern 2006-2009Adult Percentage of Patients

7/09-9/09 9/09-11/09

Total All Antipsychotics 25.7% 23.5%



Hi Dose Antipsychotic 2.0% 2.6%

2 Benzodiazepines 3.1% 3.1%

Use of Antipsychotics in Medicaid Children- 16 States, 2004-2007

• Highest rate of use in Kids under 18 yo• Highest rate of use in Kids under 6 yo• Above median use of multiple psychotropics• Median rate of high dose antipsychotic use• Median rate of multiple antipsychotic use• Fewest Gaps in therapy for antipsychotics


Child Antipsychotic Prevalence Program

Missouri Initiative for Children in Foster Care

• There are approximately 10,750 children in state custody at a given time

• Data pulled – Top diagnoses were Major Depression,

Adjustment Disorder, Attention Deficit Hyperactivity Disorder, and Post Traumatic Stress Disorder

• 28% were on a psychotropic medication

Missouri Initiative

Behavior Pharmacy Management Program

• 20% of children prescribed a medication triggered at least one quality indicator

– 6.65% were prescribed 5 or more psychotropics– 3.03% were prescribed two or more antipsychotics– 6.05% had multiple prescribers for 45 or more days

Past and Current Initiatives

• 2009 - 2011– Provided Integrated Summary of Care to Foster Care Case

Managers with pharmacy recommendations– Foster Care Case Managers did not feel qualified to

question prescribers regarding recommendations.

• Currently – For all children under 5 years old– PA all psychiatric meds– Case review by child psychiatrist

Next Missouri Initiative

• Current focus has been on the development of a second opinion review process

– Initially addressing children on more than 5 psychotropics

– Plans to address use of multiple antipsychotics as well

– Identification of prescriber with outlier prescriptions

Missouri Initiative

• Review of records by Board Certified Child/Adolescent Psychiatrist

• Via teleconference Reviewer discusses best practices for prescribing of patients

• Prescriber continues to be monitored to assess for change in prescribing

Missouri Initiative

• Strategies Under Consideration– Data monitoring/system development

– Clinical edits• Medication• Therapies

– Access to Clinical Consultation

– Functional Outcomes

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WebNeuro Online Standardized Assessment

1) 45 Questions assessing anxiety, depression, and stress2) 13 Standardized Cognitive Tests3) Standardized scoring for risk, resilience, and social skills4) Decision support for diagnosis and treatment5) 40 minutes to complete, three minutes to receive report

Integrative Neuroscience Assessment[home computer]

Questions [Feeling and Self Regulation] (<5 min)

Objective Cognitive Tasks [Emotion and Thinking] (30 min)

Motor Tapping

Switching of Attention

Digit Span

Maze

Memory Recognition

Choice Reaction Time

Continuous Performance

Test

Verbal Interference

Emotion Recognition

Go/No-Go Delayed Memory

Recognition

Emotion Identification

“I Find it difficult to

relax”

“I respond best to positive feedback”

English, Hebrew, Mandarin, Arabic, Spanish, Dutch, French, German

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WebNeuro Report: Patient’s Sores

Scores range from 0-10, with 10 being better

Red shading = clinically significant problem (score of 1)Orange shading = problem of borderline significance (1.5 to 3)Gray shading = healthy average range (3.5 to 7.5)Green shading = above average/superior (8 to 10)

Example Reporting of Cognitive Capacities

Reporting averages scores from tests commonly used to assess specific cognitive and emotional capacities into a psychological-level score.

In example above, Negativity Bias in assessment of negative outlook on world and a validated marker for disorder risk.

Cognitive Reporting: Cognition & ThinkingObjective assessment & reporting of emotional and cognitive processes

Supporting Treatment

Documents

MISSOURI PARTNERSHIP