FL Medicaid Drug Therapy Management Program for Behavioral Health Monitoring for Safety and Quality

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1 FL Medicaid Drug Therapy Management Program for Behavioral Health Monitoring for Safety and Quality April 23, 2014 Pensacola, FL

2 Presentation Objectives To briefly describe the program and how its components encourage quality prescribing practices To describe the expert panel process and its output To describe how data and feedback changed what we are doing

3 Medicaid Drug Therapy Management Program (Ch. 409 Florida Statutes) Improve the quality of care and behavioral health drug prescribing practices based on best practices guidelines Improve patient adherence to medication plans Reduce clinical risk Lower prescribed drug costs

4 Overall Strategies Develop and adopt best practice medication guidelines for major behavioral health illnesses Provide educational and technological tools that promote high quality prescribing Educate consumers

5 Monitoring for Safety and Quality Are the Cornerstones Collaborative development of evidence and consensus-based psychotherapeutic medication guidelines children & adults Collaborative development of edits to review practices through analysis of pharmacy claims Distribution and marketing of guidelines and edits through medical societies and publication in state medical journals Program website - Added in 2014: o Psychotropic Medication Recommendations for Target Symptoms in Youth with Neurodevelopmental Disorders o Summary for Monitoring Physical Health and Side-Effects of Psychiatric Medications in the SMI Population

6 Conditions Reviewed: Adults Adults Acute Bipolar Disorder- Depression Acute Bipolar Disorder-Mania Bipolar I Continuation/Maintenance Therapy Medication Recommendations for Bipolar Disorder Treatment of Adult Major Depressive Disorder Nonpsychotic Treatment of Adult Major Depressive Disorder Psychotic Approaches to Treatment Resistant Depression Treatment of Schizophrenia Recommended Medications for the Treatment of Schizophrenia Summaries of the Most Recent Updates of the Literature Regarding Bipolar Disorder, Depression and Schizophrenia

7 Conditions Reviewed: Children Children Under Age 6 Children Principles of Practice Regarding the Use of Psychotropic Rxs <6 YO Dosing Recommendations Regarding the use of Antipsychotic Rxs < 6 YO ADHD Medications Guidelines for Children Under Age 6 Anxiety Disorders in Children Under age 6 Disruptive Behavior Disorder or Severe Aggression in Children 3-5 YO Major Depression in Children Under Age 6 Children and Adolescents Ages 6-17 ADHD Anxiety Disorders Bipolar I Acute or Mixed Mania Chronic Impulsive Aggression Major Depression Post Traumatic Stress Disorder

8 Identifying and Intervening on Unusual Practices Edits to identify patterns of unusual prescribing Monthly analysis of claims against edits (data filters) Targeting Prescribers based on volume of unusual practices Intervention include specific communications(certified mail with receipt signature) detailing patients and clinical issues Psychiatrist consultant peer-to-peer visits with medical records reviews

9 Unusual Practice Edits: High Dose indicator: Adults and Children Defined as a total daily dose exceeding FDA/manufacturer recommendations either use of a single agent or from a combination of 2 or more APs As determined by the Florida Expert Panel (Children, requires PA) Currently no evidence to support practice as a long-term strategy Should be rarely used and then for a time-limited trial High dose is flagged as a quality indicator

10 Unusual Practice Edits: Polypharmacy Adults and Children > 2 antipsychotics for greater than 90 days concurrently 3 antipsychotics for greater than 90 days concurrently 3 or more antipsychotics for greater than 90 days concurrently 5 or more different classes of psychotropic medications concurrently

11 General Principles: Monitoring for Safety and Quality Use of Measurement-Based Care; o Treatment targets need to be precisely defined o Effectiveness and safety/tolerability of medication treatment must be systematically assessed by methodical use of appropriate rating scales and side-effect assessment protocols - CGI and BPRS for schizophrenia - PHQ9 or HRSD or MADRS for major depressive disorder - Young Mania Rating Scale and HRSD for Bipolar Disorder Collaborative Treatment Decision-Making o Ongoing callibration of expected outcomes and progression towards goals

12 What the Evidence Tells US Treatment needs to be individualized o No best agent or best dose of agent for all o Careful monitoring is absolutely necessary o Clinical judgment and skill important Antipsychotic dosing is key EPS avoidance without using anticholinergic is the key to purported atypical benefits Clozapine is gold standard in refractory illness Switching antipsychotic is RISKY

13 Most Frequently Prescribed Drugs at High Dose: Adults Drug (high dose) Average Number of Patients Per Quarter Haloperidol (> 20 mg) 454 Lurasidone (> 80 mg) 192 Fluphenazine (> 20 mg) 169 Risperidone (> 8 mg) 164 Quetiapine (> 1000 mg) 101 Aripiprazole (> 30 mg) 81 Olanzapine (> 30 mg) 54 Ziprasidone ( > 240 mg) 13

14 Most Frequently Prescribed Drugs at High Dose : Children Drug (high Dose) Average Number of Patients Per Quarter Risperidone Aripiprazole Quetiapine Olanzapine Ziprasidone 6-11 yo >4 mg/day yo >6 mg/day 6-11 yo >15 mg/day yo>30mg/day 6-11 yo >400 mg/day yo >800 mg/day 6-11 yo >10mg/day 12-17yo >20 mg/day 6-11 yo > 80 mg/day yo >160 mg/day Risperidone Microspheres Not recommended at any age

15 High Dose Indicator: Medical Dxs, Monitoring for Safety and Management of Physical Health Diagnoses Adults Children Parkinson EPS Acute Dystonia due to drugs Sub-Acute Dystonia due to Tremors Obesity Obesity unspecified Morbid obesity Diabetes Dyslipidemia

16 High Dose Medications: What Are We Doing? Developed a targeted communication to providers identified as high dose prescribers including: Patients who are prescribed high doses need to be engaged by their prescribers in a conversation about the risks associated with their current regimen Dose reduction should be considered if the patient is doing well Gradual medication tapers when reducing doses Use of rating scales Communication by prescribers with their primary care colleagues to address the medical causes of psychiatric symptoms (integration)

17 Percent of Prescribers Psychiatrist vs. Non-Psychiatrist Adults years Olds - CY 2013 All Claims 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 10,248 20,986 3,421 1, ,214 Antipsychotic Antidepressant Stimulants Psychiatrist Non-Psychiatrist

18 Percent of Prescriptions Psychiatrist vs. Non-Psychiatrist Adults years Olds - CY 2013 All Claims 70.0% 782, % 50.0% 319, ,294 36,098 32, % 434, % 20.0% 10.0% 0.0% Antipsychotic Antidepressant Stimulants Psychiatrist Non-Psychiatrist

19 Florida Physician Demographics Physicians Age 60 or older - Select Specialties (n=48,852) Psychiatry 47.2% Pediatrics 23.9% Internal Medicine 24.6% Family Medicine/General Practice 32.6% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0% Percent of Physicians

20 Florida Physician Demographics Physicians Age 60 or older - Select Specialties (n=48,852) Psychiatry 47.2% Pediatrics 23.9% Internal Medicine 24.6% Family Medicine/General Practice 32.6% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0% Percent of Physicians

21 Florida Physician Demographics

22 Questions Please visit our website:

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