Follow-up to Previous Reviews. Foster Children Prescribers (Nurse Practitioner Practice Sites)

Transcription

1 15 January

2 Follow-up to Previous Reviews Foster Children Prescribers (Nurse Practitioner Practice Sites) 2

3 Foster Children Prescribers (Nurse Practitioner Practice Sites) 3

4 Ongoing Reviews Buprenorphine DUR Narcotic Analgesic Studies Acne DUR Use of Psychotropic Medications in Foster Children Hepatitis C DUR 4

5 Buprenorphine DUR PMP Interconnect Search More states have been added to the list (must select each individual state to search) up to twelve now including Idaho (new ones from last quarter in RED) Colorado Illinois Indiana Kansas Michigan Minnesota Nevada New Mexico North Dakota Ohio Utah 5

6 Buprenorphine DUR Identified all participants with at least one claim paid for oral buprenorphine by Idaho Medicaid between 9/1/14 to 11/30/14. n=212 Ran Board of Pharmacy report for all of these participants to identify anyone who had received any other opioid with overlapping days of service and noted payment method (cash, Idaho Medicaid, other insurance). 6

7 Buprenorphine DUR When Idaho Medicaid identifies patients on oral buprenorphine, they are blocked from payment for any other opioid. 7

8 Buprenorphine DUR /1/2013-4/30/2013 6/1/2013-8/31/ /1/ /30/ / /28/ /1/2014-5/31/2014 6/1/2014-8/31/ /1/ /30/ Total number of participants on oral buprenorphine Participants who paid cash for an opioid while on oral buprenorphine 8

9 Buprenorphine DUR Other Opioids Mar May 2014 Other Opioids Jun Aug 2014 Other Opioids Sep Nov hydrocodone oxycodone fentanyl patch tramadol opiate cough syrup hydromorphone hydrocodone oxycodone fentanyl patch tramadol hydromorphone methadone morphine codeine hydrocodone oxycodone fentanyl patch tramadol methadone morphine codeine 9

10 Buprenorphine DUR Called Suboxone Prescribers Was prescriber aware of other opioids paid for with cash? What was the consequence to the patient? 10

11 # of patients Buprenorphine DUR 4 Contacted Prescribers of Patients Who Paid Cash for Other Opioids MD NOT aware and will counsel patient at next visit 11

12 # of patients Buprenorphine DUR 4 Patients Who Paid Cash for Other Opioids MD called us ahead of time to inform us that patient would be getting other opioids 12

13 # of patients Buprenorphine DUR Contacted Prescribers of Patients Who Paid Cash for Other Opioids 3 MD already aware and has discharged patient from their Suboxone practice 9 MD aware patient had surgery/dental work/kidney stones 2 MD aware patient violated Suboxone contract, has been counseled, but remaining in Suboxone program 13

14 Buprenorphine DUR Feedback from prescribers Prescribers are appreciative of the information provided More prescribers are using the Idaho Board of Pharmacy PMP report 14

15 Buprenorphine DUR Questions/Comments??? 15

16 January

17 Background Hydrocodone combination products are the most frequently prescribed opioids in the United States and among the most widely diverted and abused pharmaceuticals Rescheduling Recommendation was based on recommendation from an FDA Public Advisory Committee meeting held January 2013 (19-10 vote) Proposed rule published in March 2014 and 600 public comments were received HHS performed an 8-Factor Analyses DEA published the final rule on August 22, 2014 in the Federal Register Reschedules hydrocodone combination products from Schedule III to Schedule ll Went into effect 45 days after publication (October 6) 17

18 Specifics Went into effect October 6, 2014 All new prescriptions treated as Schedule II Prescriptions written prior to October 6, 2014 with refills can be refilled until April 8,

19 DUR Board Questions How will this effect other Opioid initiatives? > 1 long-acting > 1 short-acting > 300 mg daily morphine equivalents What shift in other agent utilization will be seen? Tramadol Acetaminophen with Codeine 19

20 9000 Hydrocodone Combination Products and Alternatives by Claim Count Hydrocodone Combinations Tramadol/Tramadol + APAP APAP and Codeine Sep-14 Oct-14 Nov-14 Dec-14 20

21 $180,000 Hydrocodone Combination Products and Alternatives by Expenditures $160,000 $140,000 $156,215 $137,568 $143,492 $130,098 $120,000 $100,000 $80,000 $60,000 Hydrocodone Combinations Tramadol/Tramadol + APAP APAP and Codeine $40,000 $20,000 $22,363 $22,500 $21,586 $21,118 $- $6,630 $9,140 $8,163 $7,391 Sep-14 Oct-14 Nov-14 Dec-14 21

22 Hydrocodone Combination Products and Alternatives by Unique Recipients Hydrocodone Combinations Tramadol/Tramadol + APAP APAP and Codeine Sep-14 Oct-14 Nov-14 Dec-14 22

23 Hydrocodone Combination Product Prescription Characteristics $19.27 $19.45 $20.55 $20.59 Average Quantity per Claim Average Payment per Claim Average Days Supply per Claim Sep-14 Oct-14 Nov-14 Dec-14 23

24 Questions/Comments??? 24

25 Christopher Johnson Pharm.D Pharmacy Services Specialist 25

26 Isotretinoin Reviewed claims from 7/1/2014 to 11/30/2014. Total Claims: 975 with total cost of $375,882 Total unique patients: 298 Male: 171 Average age: 17 (12 to 50) Female: 127 Average age: 19 (13 to 42) 26

27 Isotretinoin 27

28 Isotretinoin 28

29 Isotretinoin 29

30 Isotretinoin 30

31 Isotretinoin 31

32 Isotretinoin Questions/Comments? 32

33 33

34 Calendar Year

35 Use of Psychotropic Medications in Foster Children Comparison of Idaho Medicaid to Five States in GAO Study Percentage of children (0-17 years old) prescribed psychotropic Medications in named State and year Foster Children Nonfoster children Ratio of foster to nonfoster children Florida % 8.2% 2.7 Massachusetts % 10.2% 3.8 Michigan % 7.9% 2.7 Oregon % 4.8% 4.1 Texas % 7.1% 4.5 Idaho % 14.8% 2.6 Idaho % 14.8% 2.9 Idaho % 15.7 % 2.8 Idaho % 15.8%

36 Percentage of Children Percentage of Children Receiving Psychotropic Medications Over Time 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Foster 34% 39% 39% 41% 43% 45% 44% Non-Foster 14% 15% 14% 14% 15% 16% 16% 36

37 January 1, 2013 through December 31,

38 Foster Children on Psychotropic Drugs Total Foster Children meeting criteria Psychotropic Drug Claims Total Foster Children on Psychotropic Drugs High Utilizers * Percent High Utilizers % 21,418 7, % Claims/Child Total Cost Foster Children $ 2,048,007 $ 414, % Cost/Child $ 756 $ 6,100 ( range $71-$22,513) * > 50 psychotropic drug claims during calendar year

39 Age and Gender Characteristics for High Utilizers Age and Gender (> 50 claims for time period) Male 0-6 Female 7-12 Male 7-12 Female Male Female 39

40 Next Steps: Evaluation Request chart notes as needed Identify prescriber(s) for patterns Identify potential medication related problems based on best-practice and evidence-based guidelines Untreated indications Improper drug selection Subtherapeutic dosage Failure to receive medication Overdosage Adverse Drug Reactions Drug Interactions Medication use without indication Outcome assessment elimination or reduction of patient s symptomatology Evaluate for presence and need for psychotherapy 40

41 Next Steps: Action Intervention letter to prescriber if needed Referral to Optum if deemed necessary Follow-up in 6 months 41

42 Christopher Johnson Pharm.D Pharmacy Services Specialist 42

43 Hepatitis C Agents Data collected from 10/1/2014 to 1/13/2015 Total of 9 patients approved: Female: 5 Average Age: 56 (49-63) Male: 4 Average Age: 56 (53-60) 43

44 Hepatitis C Agents 44

45 Hepatitis C Agents 45

46 Hepatitis C Agents 46

47 Hepatitis C Agents 47

48 Hepatitis C Agents Total Payment: $1,884,634 Total Claims: 70 48

49 Hepatitis C Agents 49

50 Hepatitis C Agents Questions/Comments? 50

51 Current Interventions/Outcomes Studies Multiple Dosage Forms of Ziprasidone Prescribed Concomitantly Oxycodone DUR Methadone DUR Colcrys DUR 51

52 Multiple Dosage Forms of Ziprasidone Prescribed Concomitantly Paid claims for oral ziprasidone between 9/1/2014 and 11/30/2014 were evaluated. 52

53 Multiple Dosage Forms of Ziprasidone Prescribed Concomitantly Olanzapine 10/19/13 1/19/2014 Ziprasidone 9/1/ claims 869 unique recipients $246, claims 473 unique recipients $96,063 53

54 Multiple Dosage Forms of Ziprasidone Prescribed Concomitantly Usual maximum FDA approved daily dose for ziprasidone (Geodon) is 160mg. Capsules available in the following strengths: 20mg 40mg 60mg 80mg 54

55 Multiple Dosage Forms of Ziprasidone Prescribed Concomitantly Daily Dose 160mg > 160mg 19, 22% 66, 78% 55

56 Multiple Dosage Forms of Ziprasidone Prescribed Concomitantly 25 Daily dose 160mg, n= Patients 0 60mg 80mg 100mg 120mg 140mg 160mg 56

57 Multiple Dosage Forms of Ziprasidone Prescribed Concomitantly Daily dose > 160mg, n= mg 200mg 240mg 280mg 320mg Patients 57

58 Multiple Dosage Forms of Ziprasidone Prescribed Concomitantly Patients were identified who were on two capsule strengths concomitantly for at least two consecutive fills for greater than FDA approved daily dose. Olanzapine 70 patients Ziprasidone 19 patients 58

59 Multiple Dosage Forms of Ziprasidone Prescribed Concomitantly Plan: Send out DUR letters to prescribers of patients currently receiving > 160mg daily. Magellan will create a new initiative to make therapeutic duplication for multiple capsule strengths of ziprasidone a hard stop edit. When this new initiative is ready to be implemented, Idaho Medicaid will run a more current three month look at patients receiving multiple dosages to identify any new patients since this data was evaluated. 59

60 Multiple Dosage Forms of Ziprasidone Prescribed Concomitantly Paragraph in letter: The usual maximum recommended daily dosage for ziprasidone is 160mg (80mg twice daily). The DUR board is reviewing Idaho Medicaid participants who are receiving more than 160mg/day of ziprasidone using multiple capsule strengths. As of 3/1/15, multiple strengths of ziprasidone capsules will no longer pay at the pharmacy without prior authorization. During a recent review it was noted that your patient, $MEMBER NAME, has been receiving more than 160 mg/day of ziprasidone using multiple capsule strengths. If you feel that it is clinically justified for your patient to remain on multiple strengths of ziprasidone capsules, please submit a quantity override prior authorization request for review by the department. A copy of this form is enclosed for your convenience. 60

61 Multiple Dosage Forms of Ziprasidone Prescribed Concomitantly Questions/Comments??? 61

62 Christopher Johnson Pharm.D Pharmacy Services Specialist 62

63 Oxycodone IR Reviewed claims from 7/1/2014 to 10/31/2014. Total Claims: 3,555 with total cost of $176,707 Total unique patients: 1,051 Male: 387 Average age: 45 (6 to 87) Female: 664 Average age: 43 (6 to 77) 63

64 Oxycodone IR 64

65 Oxycodone IR 65

66 Oxycodone IR 66

67 67

68 Oxycodone IR 68

69 Oxycodone IR 69

70 Oxycodone IR 70

71 Oxycodone IR Questions/Comments?? 71

72 Methadone Reviewed claims from 7/1/2014 to 10/31/2014. Total Claims: 1,618 with total cost of $38,929 Total unique patients: 390 Male: 145 Average age: 47 (15 to 68) Female: 245 Average age: 44 (18 to 68) 72

73 Methadone 73

74 Methadone 74

75 Methadone 75

76 Methadone 76

77 Methadone 77

78 Methadone 78

79 Methadone 79

80 Methadone Questions/Comments??? 80

81 Colcrys DUR Background In June 2006, the FDA announced a new drug safety initiative to remove unapproved drugs from the market, including a final guidance entitled Marketed Unapproved Drugs-Compliance Policy Guide (CPG). Notice that any illegally marketed product is subject to FDA enforcement at any time Clarified that the FDA intends to use a risk-based approach to enforcement July 29, 2009: Colcrys approved for Familial Mediterranean Fever (FMF) July 30, 2009: Colcrys approved for Acute Gout Flares October 16, 2009: Colcrys approved for Chronic Gout September 26, 2014: Mitigare approved for prophylaxis of gout flares 81

82 Colcrys DUR 2012 American College of Rheumatology Guidelines for Management of Gout states that NSAIDS, corticosteroids, or oral colchicine are all first-line options for the treatment of acute gout. The guidelines also state that low-dose NSAID therapy or oral colchicine are firstline for gout attack prophylactic therapy for the treatment of chronic gout. These recommendations are based on level of evidence and safety but do not take cost-effectiveness of therapies into consideration. 82

83 Colcrys DUR Prior authorization is not needed for preferred oral NSAIDs or for corticosteroids. Idaho Medicaid s current therapeutic criteria for Colcrys ACUTE GOUT Contra-indication or failure to either NSAID or corticosteroid (oral or injectable) CHRONIC GOUT (used in conjunction with oral allopurinol) Contra-indication or failure to NSAID OTHER INDICATIONS Case by case evaluation 83

84 Colcrys DUR Colcrys Utilization # Patients

85 Colcrys DUR 230 Colcrys Utilization # claims

86 Colcrys DUR Total Payment $ $50,000 $45,000 $40,000 $35,000 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0 Colcrys Utilization $35,070 $44,

87 Colcrys DUR Colcrys Utilization Cost per Claim $ $200 $195 $190 $185 $180 $175 $170 $165 $160 $155 $150 $145 $164 $

88 Colcrys DUR Diagnoses for patients with paid claims Aug 1 - Oct 31, 2013 n=33 Sep 1 - Nov 30, 2014 n=

89 Colcrys DUR September 1 November 30, 2014 prior authorizations Total of 18 requests received 15 approved 3 denied 89

90 Colcrys DUR Prior Authorization denials 1. Requested for acute gout; No trial and failure to either NSAIDs or corticosteroids. 2. Requested for chronic gout; request stated persistent symptoms on allopurinol but not consistently filling allopurinol. 3. Requested for chronic gout; patient not on allopurinol. 90

91 Colcrys DUR Recommendations 1. Continue to require prior authorization for Colcrys. From previous DUR, off-label use for Colcrys exists. From current DUR, not all patients meet Idaho Medicaid s current therapeutic criteria. 2. Remind pharmacies that they can run a prescription for 3 tablets for acute gout as an emergency override. 3. Consistently request renal function numbers rather than just accept chronic kidney disease on prior authorization request. 4. Review duration of colchicine used for prophylaxis of gout flares. Prophylactic therapy may be beneficial for at least the first six months of uric acid lowering therapy. Don t just renew prior authorization annually for chronic gout prophylaxis. 91

92 Colcrys DUR Questions/Comments??? 92

93 Proposed Studies for Next Quarter: Atypical Antipsychotics Synagis Prescriber Profiling 93

94 Atypical Antipsychotics 94

95 Idaho Medicaid DUR 95

96 Prescriber Profiling Tami s Wish List Prescriber Identifier Specialty Claims per Month Patients (members) per Month Claims per member per Month Drug Expenditures per Month Drug Expenditures per Claim per Month Drug Expenditures per member per month PDL Compliance Mark s Deliverable Claim Physician ID Taxonomy Code/Taxonomy Description Total Claims Average # of Members per physician Total Payment Amount Average Payment per Claim Average Payment per Member 96

97 Prescriber Profiling Comparison to Average Highest Prescribers by volume and by expenditures Top 25, 50 or 100 What to do with the data Feedback to physicians Peer Comparative Data Use with academic detailing? 97

98 Prospective DUR Report History Errors: DD drug-to-drug PG drug to pregnancy TD therapeutic duplication ER early refill MC drug-to-disease Non-History Errors: PA drug-to-age HD high dose LD low dose SX drug-to-gender 98

99 Prospective DUR Report Idaho Medicaid Program ProDUR Message Report December 2014 ProDUR ProDUR Message Message Message Severity Count Amount Drug To Drug 1 2,110 $637, ,753 $3,741, ,618 $16,256, $ Drug To Gender $28, ,983 $233, Drug To Known Disease 1 70,673 $11,931, ,429 $57,082, ,523 $73,037, Drug To Pregnancy 1 29 $ $55.03 A 8 $ B 77 $25, C 153 $16, D 24 $ X 6 $54.00 Duplicate Therapy 0 123,254 $29,915, Min Max 0 29,754 $7,044, Too Soon Clinical 0 22,563 $5,218, ALL 938,182 $205,171, Total Number of Claims with Messages 226,263 Average ProDUR Message Per Claim

100 DUR Winter Newsletter Brainstorm for new topics 100

101 DUR Board Meeting January 15,

102 Overview of Medicaid Drug Use July 1, 2013 June 30, 2014 Drug Expenditures $158,063,347 Paid Claims 2,132,033 Utilizers 55,899 Claims/Utilizer 3.18 Cost/Claim $ Cost/Utilizer $ Percent of Medicaid Eligibles that are drug utilizers = 18 % Percent of Medicaid Program Budget Spent on Drugs = 10% 102

103 Drug Expenditures vs Actual Cost July 1, 2013 June 30, 2014 Total Drug Expenditures $ 158,063,347 CMS Drug Rebates Collected $ 79,091,576 Supplemental Rebates Collected $ 5,328, 762 Net/Net Cost $ 73,643,238 Rebate Percentage = 46% 103

104 Therapeutic Classes with Highest Payment Amount Therapeutic Class Claims % of Total Claims AAP Antipsychotics aripiprizole AAP Antipsychotics all other Payment Amount % of Total Payment Utilizers PUPY 22,087 1 % $ 15,033, % 3,617 $ 4,156 73, % $ 12,510,984 8 % 8,342 $ 1,500 Anticonvulsants 127,501 6 % $ 11,572, % 14,114 $ 820 Insulins 23, % $ 7,412, % 2,411 $ 3,074 Narcotic Analgesics 173, % $ 6,652, % 38,098 $ 175 Stimulants amphetamine type Stimulantsmethylphenidate type Antihemophilic Factors Beta-adrenergic 38, % $ 6,338,293 4 % 5,725 $ 1,107 46, % $ 6,289,359 4 % 6,488 $ , % $ 4,717,397 3 % 19 $ 248,284 3 % $ 3,468, % 23,952 $ 145 Multiple Sclerosis % $ 3,384, % 104 $ 32,

105 Top 10 Drugs by Expenditure Drug B/G Total Claims Total Payment Amount Cost per Utilizer Cost per Claim Abilify oral B 21,706 $ 14,539,985 $ 4,047 $ Invega Sustena B 2,649 $ 3,633,347 $ 10,531 $ 1, dextroamphetamine/ amphetamine G 22,439 $ 3,616,719 $ 1,005 $ methylphenidate G 28,942 $ 3,432,880 $ 683 $ duloxetine G 12,728 $ 2,787,187 $ 1,536 $ Vyvanse B 14,979 $ 2,618,392 $ 1,056 $ Strattera B 10,565 $ 2,286,399 $ 1,284 $ Humira B 878 $ 2,254,321 $ 14,734 $ 2, Seroquel XR B 3,996 $ 2,086,279 $ 2,918 $ Lantus Solostar B 5,818 $ 1,884,725 $ 1,744 $ Novoseven B 17 $ 1,757,482 $ 1,757,482 $ 103,

106 Top 10 Drugs by Claims Amount Drug B/G Total Claims Total Payment Amount Cost per Utilizer Cost per Claim hydrocodone/ acetaminophen G 74,236 $ 1,573,084 $ $ omeprazole G 51,691 $ 904,608 $ $ amoxicillin G 36,736 $ 465,772 $ $ montelukast G 32,496 $ 743,809 $ $ trazadone G 31,798 $ 381,100 $ $ fluoxetine G 30,285 $ 379,300 $ $ methylphenidate G 28,942 $ 3,432,880 $ $ azithromycin G 28,281 $ 560,799 $ $ citalopram G 27,121 $ 303,158 $ $ metformin G 26,438 $ 319,773 $ $

107 90% 57% 43% 10% Brand Claims Generic/Multisource Claims Brand Expenditures Generic/Multisource Expenditures Brand Claims 215,285 Generic/Multisource Claims 1,898,369 Brand Expenditures $88,994,008 Generic/Multisource Expenditures $67,627,

108 Cost to Medicaid vs Cost to Providers Pharmacy Reimbursement Federal Rebate Supplemental Rebate Net/ Net Cost Drug D generic $ $ $ Drug D brand $ $ $ 4.65 $ Idaho Medicaid Prescription Reimbursement Average Actual Acquisition Cost plus assigned tiered dispensing fee Dispensing Fee Tiers Less than 40,000 claims a year = $ ,000 to 69,999 claims a year = $12.35 Greater than or equal to 70,000 claims a year = $

109 Improved health, improved healthcare, and lower cost for all Idahoans 109

110 How was the SHIP Developed? 2013 SHIP planning process numerous Idaho healthcare stakeholders participated over 6 month planning period. 60 focus group and town hall meetings held in Over 300 individuals involved in the planning process. SHIP Steering Committee received recommendations from four workgroups: Network Design Quality Measures HIT/Data Payment Reform 110

111 How was the SHIP Developed? SHIP Steering Committee considered recommendations and finalized plan design. SHIP submitted to CMMI December 2013 as product of planning process. Governor Otter signed executive order creating Idaho Healthcare Coalition to guide SHIP implementation. SHIP was basis of design for model testing proposal/grant application submitted to CMMI in July

112 Primary SHIP Goal Redesign Idaho s healthcare delivery system to evolve from a fee-for-service, volume-based system to a value-based system of care based on improved health outcomes. 112

113 SHIP Proposal Goals Goal 1: Build 180 PCMH primary care practices with 900 primary care providers serving 1.3M Idahoans Goal 2: Adoption and use of EHRs and IHDE connections among the 180 Model Test PCMHs, and across the Medical Neighborhood. Goal 3: Establish 7 Regional Collaboratives to support the integration of each PCMH with the broader Medical Neighborhood. Goal 4: Improve rural patient access to PCMH by developing 75 virtual PCMHs. 113

114 SHIP Proposal Goals Goal 5: Build a statewide data analytics system. Goal 6: Align payment mechanisms across payers to transform payment methodology from volume to value. Goal 7: Reduce healthcare costs 114

115 Idaho SHIP Model Elements Strong primary care system in rural and urban communities throughout the state. Patient Centered Medical Homes (PCMH) foundational. Medical Neighborhood links PCMH to other needed health and social services. Regional Cooperatives (RC) support local primary care providers and medical neighborhood. 115

116 Idaho SHIP Model Elements Idaho Healthcare Coalition (IHC) guides SHIP model implementation at the state level Health information is linked electronically by EHR and HIT. Data analytics used to improve individual patient care and address population health trends. Payment methodologies are aligned across major payers. Patient engagement/accountability key to success. 116