MICHIGAN MEDICAID DRUG UTILIZATION REVIEW ANNUAL REPORT

Transcription

1 State of Michigan Department of Community Health MICHIGAN MEDICAID DRUG UTILIZATION REVIEW ANNUAL REPORT Prospective and Retrospective Drug Utilization Review And Cost Analysis Federal Fiscal Year 2009

2 Michigan Medicaid Drug Utilization Review 2009 Annual Report I. Program Background and History The Medicaid Drug Utilization Review (DUR) Program was created by the Omnibus Budget Reconciliation Act of 1990 (OBRA 90). The main emphasis of the program is to promote patient safety by an increased review and awareness of outpatient prescribed drugs. States were encouraged by enhanced federal funding to design and install point-of-sale (POS) electronic claims management systems that interface with their Medicaid Management Information System (MMIS) operations. The annual report requirement provides a measurement tool to assess how well state Medicaid programs have implemented the DUR program and the effect DUR has had on patient safety and provider prescribing habits. The purpose of Michigan s DUR program is to improve the quality of pharmaceutical care by ensuring that prescriptions are appropriate, medically necessary, and that they are not likely to result in adverse medical results, in accordance with OBRA 90. DUR assesses data on drug use against predetermined standards, consistent with peer-reviewed literature, and the recommendations of the State s DUR Board. The major components of DUR are Prospective DUR (ProDUR) and Retrospective DUR (RetroDUR). ProDUR provides for a review of drug therapy before each prescription is filled or delivered to a recipient. The review must include screening for items such as therapeutic appropriateness, over-utilization and under-utilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindication, drug-drug interactions, incorrect drug dosage or duration of drug treatment and clinical abuse/misuse. This is accomplished by messages sent from the point-of-sale system to the dispensing pharmacist when the claim is submitted for payment. The messages may be soft messages messages which are sent as information, but do not stop the processing of the claim, or hard messages messages which stop processing and payment of the claim. Hard messages, or edits, are resolved in one of two methods. Pharmacists may override a hard edit at point-of-sale by submitting a code, which provides additional information about the patient. This information is compared to criteria to allow for exception and payment. A physician may have a hard edit overridden by calling and providing additional clinical information to staff. If the information meets criteria for exception then an authorization for payment is entered into the point-of-sale computer system. RetroDUR retrospectively assesses data on drug use against explicit predetermined standards and introduces appropriate remedial strategies to improve the quality of care. This may be accomplished through a variety of methods, including letters to specific providers about specific recipients, educational mailings or personal visits to providers by pharmacists trained to conduct educational visits. 1

3 Michigan Medicaid Drug Utilization Review 2009 Annual Report A contract between the Michigan Department of Community Health (MDCH) and First Health Services Corporation (FHSC) for ProDUR services and related activities was begun as a point-of-sale system on July 5, 2000 in conjunction with electronic claims adjudication. RetroDUR services and related activities were begun in October The Michigan DUR Board meets on a quarterly basis to review activities and reporting associated with both the ProDUR and RetroDUR. All ProDUR and RetroDur activities are carried out under the supervision of both the MDCH and the Michigan DUR Board. On December 19, 2002 FHSC began using the System Excellence (SX) processing system for Michigan Medicaid point of sale (POS) claims processing, which utilizes clinical criteria for ProDUR provided by First Data Bank Corporation (FDB). This system was updated for Michigan Medicaid on August 16, 2003 to the NCPDP transmission standard 5.1 in compliance with HIPAA regulations. RetroDUR criteria utilized include proprietary FHSC RetroDUR clinical criteria as well as custom criteria created specifically for the Michigan Medicaid program. This DUR program annual report encompasses the drug utilization review activities and outcomes that have occurred during FFY Included are ProDUR alerts and intervention statistics, RetroDUR alerts and intervention statistics. The Medicaid enrollment continues to grow, with an average total enrollment of 1,613,636 for FFY 2009, a 3.1% increase over FFY Presently 65% of the Medicaid patients are enrolled in Managed Care Organizations. The remaining 35% are in Fee for Service (FFS). This is a similar distribution as in FFY 2008 (62% and 38%, respectively). The DUR Board reviews prescribing patterns for primarily the FFS patient population. While the DUR Program addresses patient safety, Michigan believes safe and effective pharmaceutical prescribing results in cost effective medicine. The Michigan Medicaid program has aggressively addressed pharmacy expenditures. Other initiatives of our pharmacy program include daily Maximum Allowable Cost (MAC) pricing review, use of quantity limits, dose optimization (dose consolidation), e-prescribing and the multi state pooling initiative. It is through these efforts Michigan continues to provide safe and effective treatment of citizens served by the Medicaid program. E-prescribing was initiated for Michigan Medicaid in September Utilization of electronic prescriptions continues to grow among Michigan Medicaid prescribers. In March 2009, 16.5% of the prescribers writing a prescription paid for by Michigan Medicaid transmitted the prescription electronically to the pharmacy. This on-going program increases prescription drug safety by reducing errors due to hand writing issues and by giving prescribers the opportunity to review a patient s medication history prior to ordering a new drug. 2

4 Michigan Medicaid Drug Utilization Review 2009 Annual Report This report was prepared by Annette Paul, R.Ph., Clinical Account Manager at First Health Services Corporation. Questions regarding this report should be directed to Debera H. Eggleston, M.D., Office of Medical Affairs, Michigan Medical Services Administration at (517)

5 Michigan Medicaid Drug Utilization Review 2007 Annual Report II. Prospective Drug Utilization Review (ProDUR) The POS/ProDUR system provides Michigan Medicaid with the ability to minimize potential drug interactions and drug-induced illness or side effects. Adverse reactions from drugs occur more frequently when a recipient visits more than one physician and/or more than one pharmacy to obtain medication. The dispensing pharmacist is provided with access to a comprehensive patient/drug incompatibility database. Averting adverse drug effects may result in the prevention of subsequent physician visits, hospitalizations or additional drug therapy. ProDUR achieves this objective by reviewing all claims for therapeutic appropriateness before a medication is dispensed, review of the recipient s available drug claims and history for incompatible or duplicative therapy and focusing on those recipients at the highest level of risk for harmful outcome. Utilization Analysis First Health Services ProDUR system assists the pharmacist with the detection, evaluation and counseling components of predispensing drug therapy screening by addressing ten different situations in which potential medication problems may exist. ProDUR messages and alerts are categorized as criteria-based or non-criteriabased. Criteria-based alerts are based on standard drug criteria from First Data Bank Corporation. Criteria-based alerts are separated into history and nonhistory alerts as indicated below and in Figure 1 on page 5. History alerts require a drug claim in the drug claim history to interface with the current claim. Non-history alerts are based on the current claims information. Non-criteriabased alerts are the early refill (ER) messages. The screening areas identified by ProDUR criteria are: Criteria Based Alerts: History Alerts: Drug-Drug Interactions (DD) Alert occurs when a drug to be dispensed may interact with another drug filled within the previous eight weeks from any participating pharmacy. Alerts are sent to pharmacies only on the most clinically significant drug interactions. Late Refill (LR) Alert occurs when a patient has waited to refill their maintenance medications beyond the specified days supply of the previous fill. Late refill is also known as underutilization. 4

6 Plan Level Edits (PP) Alert occurs when a drug is dispensed that meets specific criteria established by the individual plan. Michigan Medicaid currently uses this edit only for the ulcer medication edit to monitor acute ulcer medication therapy beyond a specified number of days. Therapeutic Duplication (TD) Alert occurs when a drug to be dispensed is in the same therapeutic class or is considered as having the same action, but is not clinically synergistic, as another drug filled within a specified time period. An example of this would be Oxycontin and Vicodin. Non-History Alerts: Drug-Age Contraindication (PA) Alert occurs when a drug to be dispensed is not recommended for use in the age group of the patient. Severity is assigned by First Data Bank. Drug to Inferred Disease (DC) Alert occurs when a drug is dispensed that may be contraindicated in a disease state which is inferred by drugs in the recipient s claim history. The inferred diseases are determined by First Data Bank. Drug to Gender (SX) Alert occurs when a drug is dispensed that is not recommended for use by the gender indicated on the recipient s eligibility file. Drug to gender is a criteria-based, nonhistory alert. Excessive Drug Dosage (MAX) Alert occurs when the calculated milligram dose per day of a drug exceeds the recommended daily dosage. The criteria for excessive daily dose may be age-specific. Insufficient Daily Dose (MIN) Alert occurs when the calculated milligram dose per day of a drug is less than the minimum recommended dosage. The criteria for insufficient daily dose may be age-specific. 5

7 Non-Criteria Based Alerts: Early Refill (ER) Alert occurs when a prescription is refilled before 75% of the previously filled prescription s days supply has elapsed. Early refill is a non-criteria based, non-history alert. Michigan Medicaid denies claims for selected ProDUR messages, including early refill (ER), selected therapeutic duplication (TD), drug interactions (DD), plan level edits (PP), drug to gender (SX) and prerequisite therapy (SR). These denial edits were developed and approved by the MDCH and the Michigan DUR Board. For FFY 2006, it was decided to discontinue claim denials for ingredient duplication (ID), which was found to be less meaningful than the therapeutic duplication (TD) edit. The denials for therapeutic duplication are for drugs in the narcotic analgesic class only. For all denials involving DD and TD, the pharmacist may override the edit by entering the appropriate override code as established by the MDCH. Other denials may only be overridden after consultation by the dispensing pharmacy or prescriber with the clinical personnel at FHSC. Figure 1: ProDUR Alert Categories ProDUR Criteria Based Alert Categories History Alerts Non-History Alerts DD Drug-Drug Interactions PA Drug-Age Conflict PG Pregnancy Conflict MAX Excessive Daily Dose TD Therapeutic Duplication MIN Insufficient Daily Dose LR Late Refill DC Drug to Inferred Disease MC Drug-Disease SX Drug to Gender PP Plan Level Edits The reporting module of the POS/ProDUR system integrates information from the therapeutic criteria, the pharmacy and medical claims history files and the recipient/provider tracking files to create monthly reports. ProDUR reporting tracks cost avoidance; frequency of ProDUR alerts by problem type, by drug and by number of claims. Reports summarizing the ProDUR alerts sent to pharmacies are presented to Michigan Medicaid and to the Michigan Medicaid DUR Board at each quarterly meeting. Table 1 (see Section VI, Tables) includes a summary of all ProDUR alerts by problem type. During an average month, FHSC processed 628,168 paid POS pharmacy claims (range 598, ,451). This is a 6.76% increase in the average number of paid POS claims per month from FFY The 6

8 average cost per claims increased from $73.81 in FY 2008 to $74.03 in FY 2009, an increase of 0.3%. This is a much lower increase than 10.5% increase seen from FFY 2007 FFY There was a 0.8% increase in the total number of ProDUR messages sent in FFY 2009 from FFY There was an average of 1.17 ProDUR messages per claim that received a ProDUR message during FFY 2009, compared with 1.18 during FFY The decrease in average messages per claim can be attributed to several factors: Continuing enhancement of the filtering process, to show more clinically significant ProDUR messages, which more closely reflect those messages seen by pharmacy providers at point of sale. The elimination of additional drugs from the Late Refill (LR) edit. An analysis of the top ProDUR alerts -- by problem type -- with the number of POS claims paid (and denied) receiving an alert for each drug, is included as Table 2 (see Section VI, Tables). Please note the following information extracted from this table: The drugs most frequently noted for drug to inferred disease (DC) interactions were fluticasone/salmeterol, budesonide, haloperidol and insulin aspartame. Insulin aspartame has replace ibuprofen in the top four alerts for this category in FFY Ibuprofen remains in the top ten alerts for this category. The drugs most frequently involved in drug-drug interactions (DD) were ziprasidone, oxybutynin, potassium chloride and tolterodine tartrate. The top drug-drug interactions were completely different in FFY 2009 compared to FFY This was due to a reassignment of severity of these drugs by First Data Bank in FFY 2009, not a shift in claims for these products. The most frequent early refills (ER) noted were alprazolam, hydrocodone, quetiapine and clonazepam. This is the exact same top four alerts in this category as in FFY 2007 and FFY The most frequent excessive dose (MAX) alerts noted were fluticasone, hydrocodone, cyanocobalamin and escitalopram. Escitalopram has replace propoxyphene in the highest alerts for dose alert list, however, propoxyphene is still in the top ten. The most frequent underutilization (LR) alerts noted were amphetamine salts, albuterol, clonazepam, and sertraline. This is the same top four as in FFY 2008, but albuterol and clonazepam have switched in the second and third places. There is an edit in the point of sale system that blocks some late refill messages from being sent to the pharmacy, even though the message is recorded in the utilization numbers. Both albuterol and amphetamine salts are on the list of drugs blocked from actual utilization messages being sent. It was felt that these drugs are utilized in a manner that conventional underutilization messaging is not appropriate. The most frequent drug-age (PA) alerts for geriatric recipients noted were diazepam, benztropine, amitriptyline, and butalbital/acetaminophen/caffeine combination. Bisacodyl dropped out of the top ten after being part of the top ten for the last three years. Chlordiazepoxide dropped from number four in FFY 2008 to number five in FFY

9 The most frequent drug-age alerts for pediatric patients were dextromethrophan/phenylephrine/chlrpheniramine, lamotrigine, zonisamide, and amphetamine salts. Dextromethrophan combination products are not covered in the Michigan Medicaid program and this alerts occurred primarily on denied claims. Amphetamine salts replaced aspirin as the number four drug on this list, though aspirin remains in the top ten at number eight. The most frequent plan protocol units (PP anti-ulcer edit) alerts were lansoprazole, esomeprazole, omeprazole and pantoprazole. Omeprazole dropped back into third place in the number of alerts in FFY 2009, though the total number of alerts for esomeprazole and omeprazole is very close. The anti-ulcer plan protocol looks at the patients history and a message is sent if the patient has received a proton pump inhibitor for more than 102 days at a higher dose. These patients require a clinical review to be able to continue the higher dose past 102 days of therapy. The most frequent drug to gender (SX) alerts were for tamsulosin, sildenafil, tadalafil and miconazole vaginal. Except for tamsulosin, the total number of alerts for each of these drugs is a small percentage of their total use. The drugs most frequently cited for therapeutic duplications (TD) alerts were quetiapine, methylphenidate, hydrocodone, and amphetamine salts. This is the same list as FFY 2008 and FFY ProDUR Analysis ProDUR cost avoidance for the Michigan Medicaid prescription drug program is the sum of the claims that were reversed or denied and not resubmitted. An example of the first type of claim is a paid claim for a diuretic, such as furosemide, which got a therapeutic duplication message because the recipient had a recent claim for another diuretic, such as hydrochlorothiazide. The dispensing pharmacist then reversed out the paid furosemide claim and did not resubmit it. An example of the second type of cost avoidance is a claim which denied for a level one severity drug interaction, such as a claim for aspirin where the recipient has a claim in their history for warfarin, and the dispensing pharmacist did not resubmit the claim with appropriate override codes in order to receive a paid claim. This is illustrated in Figure 2 (below). The ProDUR cost avoidance for FFY 2009 was $153,199,645. Table 3 (see Section VI, Tables) summarizes the FFY 2009 data. However, cost avoidance should not be interpreted as true cost savings. While the ProDUR edit may have resulted in a claim reversal or denial, it is not known what the complete impact this has on the program. There are many prescriptions that are switched after point of sale to alternative medications, which would have an improved therapeutic benefit to the patient and would not generate a ProDUR edit. The cost of this alternative medication is not reflected in the calculation of ProDUR cost avoidance. Another factor that influenced this calculation was multiple claim submission for an individual beneficiary s prescription. This would result in a number of claims and ProDUR edits for one prescription. If the provider fails to reverse the various claims, the calculations would be inflated. 8

10 Figure 2: Point of Sale Disposition of Claims Claim Denied and Not Resubmitted Cost Avoidance associated with lack of filling the prescription * Claim Denied, then Resubmitted Cost Avoidance, if any, calculated as the and Paid difference between the denied claim and resubmitted claim. Only possible if claims are in the same drug class Claim Paid, no message sent No cost avoidance Claim Paid, message sent that No Cost avoidance Does not cause claim to reject Claim Paid, message sent that Cost Avoidance not calculable due to does not cause claim to reject complexity of assessing impact. However, provider resubmits with minor adjustments or other information Claim Paid, message sent that Cost avoidance calculated as submitted does not cause claim to reject: cost of the reversed claim * however, provider reverses the claim. No other claim in same class submitted within calendar month * included in cost avoidance calculations 9

11 III. Retrospective Drug Utilization Review (RetroDUR) The goal of the Michigan Medicaid RetroDUR Program is to promote appropriate prescribing and use of medications. The RetroDUR utilization analysis, as described below, provides information which assists in the identification of patterns of inappropriate prescribing and/or medication use, alerts physicians and pharmacists to potential drug therapy problems, identifies opportunities to improve drug therapy and makes recommendations to avoid drug therapy problems. Utilization Analysis The on-going operation of the RetroDUR program is a shared responsibility of First Health Services and Michigan Medicaid. Each month, specific drug classes that have been reviewed by the DUR Board are targeted for focused review under the RetroDUR program. First Health Services then applies the specified criteria established by the Board to the prescription drug and health claims files and identifies medication regimens that do not adhere to the criteria. Copies of individual medication profiles that do not adhere to specific criteria are generated by First Health Services and sent to Michigan Medicaid Profile Reviewers for indepth review. If, based on the professional opinions of the Michigan clinical reviewers or the First Health Services Michigan Medicaid Clinical Manager, an aberrant pattern of prescribing and/or utilization is indeed present, an educational letter is sent to the prescribing physician and/or the dispensing pharmacist informing the provider of the suspected problem and requesting further information to use in resolution of the issue. After the review process is completed, the First Health Services Michigan Medicaid Clinical Manager decides which patient profiles should cause the generation of physician or pharmacy letters. First Health Services produces and mails provider letters documenting the therapeutic effects of the RetroDUR program and tracks provider responses and cost savings associated with the interventions. The Michigan Medicaid DUR Board meets quarterly to review drug criteria in specific therapeutic classes and/or drug criteria for new drugs approved by the FDA. A total of 7,679 patient profiles, or an average of 640 profiles per month, reflecting these RetroDUR exceptions were subsequently reviewed by Michigan Medicaid Profile Reviewers. They then recommended a total of 2,124 intervention letters be sent to physicians and/or pharmacist providers in FFY 2009 concerning criteria variances or other medication related clinical issues. Table 4 (see Section VI, Tables) summarizes the profiles produced and lettered. Among the problem types addressed in the intervention letters were therapeutic duplication, overutilization, and drug-drug contraindications. Letters were also sent to physicians based on new FDA warnings or changes in production labeling. The Michigan DUR Board selected RetroDUR topics and/or criteria on a quarterly basis on information in the monthly ProDUR statistics or other clinically relevant topics from the medical literature. For example, the October and November 2008 projects were related to current literature about the use of platelet inhibitors in diabetic patients. These references included the American 10

12 Diabetes Association Standards of Medical Care in Diabetes 2008, and articles that appeared in 2008 issues of the British Medical Journal and Diabetologia. The April 2009 review of methadone use was based on recommendations from the Center for Disease Control publication in February 2008 on dosing of methadone. RetroDUR responses from prescribers were tracked on a monthly basis. Details of the responses are also found in Table 4 (see Section VI, Tables). The average response rate for FFY 2009 was 27%. This is comparable with 25% in FFY Figure 3 (below) graphically displays the RetroDUR response rate. Figure 3: RetroDUR Response Rate FFY 2009 RetroDUR Response Rate FFY % 35% 30% 25% 20% 15% 10% 5% 0% Months in FFY 09 (Oct 08 - Sep 09) RetroDUR Cost Analysis The provision of high quality drug therapy not only results in improved patient health but may also result in program cost avoidance. It is important to quantify the effect of interventions on the cost of drug therapy. First Health Services uses a cost analysis model developed by the Institute for Pharmacoeconomics of the Philadelphia College of Pharmacy and Science to quantify cost avoidance. When fully applied, the cost analysis model has the ability to capture not only cost avoidance that is a direct result of the RetroDUR letter intervention process, but also avoidance due to indirect effects. This indirect effect arises when a physician applies changes in prescribing triggered by a letter intervention involving one patient to other patients in his/her practice. The model also takes into account the impact of prescription drug inflation, new drugs introduced into the market, and changes in utilization rates, recipient numbers and demographics. 11

13 The cost analysis in this report was calculated based on changes in the prescription drug costs for those patients whose profiles were identified through the RetroDUR program. Cost avoidance is tracked over a 12-month period beginning six months after the provider is sent a letter/intervention. Changes in prescription drug costs are totaled to yield overall cost avoidance for the review period. The total cost avoidance, attributed to RetroDUR, during FFY 2009 was $300, Cost avoidance attributed to RetroDUR during FFY 2008 were $495, Monthly cost avoidance may vary due to a variety of factors, including: the class selection and problem type chosen for review the lag time before the next physician visit when changes in drug therapy may be made the incremental educational and familiarity impact on the prescriber after receiving intervention letters Month-by-month cost avoidance for all active interventions (i.e. interventions which have not completed twelve consecutive months of review/tracking) vary with intensity of intervention activity. Intervention letters sent during the fiscal year, have not all completed follow-up review for one year. Consequently, the cumulative cost avoidance effect of intervention letters mailed during FFY 2009 will not be known until the end of FFY A number of the Retrodur activities for FY09 were underutilization reviews. The desired outcome of these reviews is more appropriate utilization of the medications by beneficiaries. This will result in an increased number of prescriptions, which is reflected as a decrease in cost savings to the pharmacy program, though the overall outcome to the beneficiary s health should reflect a positive outcome. Academic Detailing The Michigan DUR Board also oversees the activities of the MI Academic Detailing Program. On a quarterly basis, trained pharmacists from the Michigan Pharmacists Association (MPA) visit selected physician providers. These providers are selected based on their prescribing patterns to receive educational information on current medical topics. The topics are often selected based on information in the ProDUR or RetroDUR reports. Topics during FFY 2008 in are listed in Figure 4 below. During FFY 2008, 261 Michigan Medicaid physician providers received a personal visit from a pharmacist detailer. Of the providers targeted for academic detailing, 82% were visited. Most commonly visits were not completed due to a physician refusal to make an appointment or canceling of the appointment by the physician. Figure 4 HISTORY OF ACEDEMIC DETAILING PROJECTS 12

14 SUBJECT DATE COMPLETED # OF PHYSICIANS PROFILED # OF VISITS COMPLETED PERCENTAGE OF COMPLETIONS Smoking Cessation May Asthma 2009 November Totals

15 IV. Factors Affecting Program Drug Costs Population Analysis Overall utilization rates can be defined in a variety of ways. These include total quantity consumed per member, number of individual prescriptions, total days supply, etc. An alternative way to look at utilization rates is by considering the number of recipients taking one particular drug for one month of time. This quantity is defined as a member-month and can give a relative view of the amount of drug used by recipients over time. Data for drug usage and overall cost by age groups have been abstracted from overall claims data. The data are summarized for FFY 2009 in Table 5 (see Section VI, Tables). The age group 0-12 utilized 20.3% of total program dollars (versus 21.8% in FFY 2008). Member-months in this category decreased slightly to 15.10% from FFY 2008 levels (15.4%). The major drug expenditures were associated with the following therapeutic classes. Glucocorticoids replaced Other Hormones in this group. Unclassified Agents (primarily antihemophilia factors) class 99 Ataractics/Tranquilizers class 07 CNS Stimulants class 10 Amphetamines class 12 Anticonvulsants class 48 Bronchial Dilators class 15 Antivirals class 33 Glucocorticoids Antidepressants class 11 The age group utilized 16.6% of total program dollars (versus the 17.8% utilized in FFY 2009). Member-months in this category decreased to 11.3% from FFY 2008 levels. The major drug expenditures were associated with the following therapeutic classes. The top classes are the same as FFY 2008, but the antidepressant class has moved down from second position to sixth. Antaractics/Tranquilizers class 07 Unclassified class 99 Anticonvulsants class 48 CNS Stimulants class 10 Amphetamines class 12 Antidepressants class 11 Other Hormones class 64 Diabetic Therapy class 58 The age group utilized 27.8% of total program dollars (versus 27.4% in FFY 2008). Member-months in this category increased slightly 26.5% relative to 14

16 FFY 2008 level of 26.3%. The major drug expenditures were associated with the following therapeutic classes. The list is essentially the same as in FFY 2008 with anticonvulsants moving up one in the ranking to second place and antidepressants falling from second place to fourth. Narcotic analgesics moved up one slot past oral contraceptives in total costs. Ataractics/Tranquilizers class 07 Anticonvulsants class 48 Unclassified class 99 Antidepressants class 11 Antivirals class 33 Narcotic Analgesics class 40 Contraceptives, oral- class 63 Bronchial Dilators class 15 Diabetic Therapy - class 58 The age group utilized 34.4% of total program dollars, an increase relative to FFY 2008 (32.4%). Member-months in this category increased slightly to 40.5% from FFY 2008 levels (39.9%). The major drug expenditures were associated with the following therapeutic classes. Antineoplastics have replace Gastrointestinals in the top classes for this age group. Antidepressants have moved down from second to fourth place, consistent with what is seen in the other age groups: Ataractics/Tranquilizers class 07 Antivirals class 33 Anticonvulsants class 48 Antidepressants class 11 Unclassified class 99 Narcotic Analgesics class 40 Diabetic Therapy class 58 Bronchodialtors class 15 Antineoplastics class 30 The age group > 65 utilized 0.7% of total program dollars (versus 0.6% in FFY 2008). Member-months in this category decreased slightly to 6.7% from FFY 2008 levels (6.9%). The major drug expenditures were associated with the following therapeutic classes. Class 41, non-narcotic analgesics has moved up to the second most expensive class in this age group from fifth place in FFY Ataractics/Tranquilizers class 07 Analgesics, non-narcotic, general - class 41 Anti-Ulcer/Other GI Agents class 01 Antihistamines - class 14 Miscellaneous class 99 Hematinics class 88 Water soluble vitamins class 81 15

17 The twenty top therapeutic classes, contributing most to cost for each age category, are listed in Table 6 (see Section VI, Tables). New Drugs Another factor, which must be considered when analyzing yearly drug expenditures, is the impact of new FDA-approved drugs and dosage forms. These new agents represent costs which sometimes cannot be anticipated and have the potential to inflate drug budgets, especially if the agents are high cost. The top new drugs, listed in Table 7 (see section VI, Tables), contributed $973,547 to FFY 2009 Michigan Medicaid drug costs. While both the costs of the top 30 new drugs and total drug costs for the program have both risen over FFY 2008 level, the percentage of the costs of the new drugs has remained exactly the same at 0.17%. 16

18 VI. Tables 17

19 Michigan Medicaid Program Table 1 ProDUR Message Report FFY 2009 ProDUR Message ProDUR Severity Message Count Message Amount Acute To Maintenance 1 50,715 $10,443, Drug To Drug 1 15,349 $5,082, Drug To Gender 1 2,016 $598, Drug To Geriatric 1 59,176 $2,424, Drug To Inferred Dis 1 343,473 $54,197, Drug To Pediatric 1 41,923 $8,550, Duplicate Therapy 0 2,050,728 $592,404, Min Max 0 445,704 $98,712, Too Late 0 1,145,265 $244,898, Too Soon Clinical 0 793,765 $171,309, ALL 4,948,114 $ Total Number of Claims with Messages 4,241,272 Average ProDUR Message Per Claim 1.17 ProDUR Severity 1 = High Importance Severity Rating is assigned by First Data Bank, Inc. CMS FFY 2009 Table 1 1

20 Michigan Medicaid Table 2 ProDUR Encounters by Problem Type Problem Drug # Claims # Alerts Alert % # Denial # Paid Type Alerts Alerts Proton Pump LANSOPRAZOLE 77,574 17, % 14,541 3,372 Inhibitor Edit PP ESOMEPRAZOLE MAG 42,699 12, % 10,372 2,585 TRIHYDRATE OMEPRAZOLE MAGNESIUM 73,318 6, % 5, OMEPRAZOLE 83,172 5, % 1, PANTOPRAZOLE SODIUM 18,783 2, % 2, RABEPRAZOLE SODIUM 2, % CMS FFY 2009 Table 2 1

21 Michigan Medicaid Table 2 ProDUR Encounters by Problem Type Problem Drug History # Claims # Alerts Alert % # Denial # Paid Type Alerts Alerts Drug To Drug ZIPRASIDONE HCL PALIPERIDONE 51, % DD OXYBUTYNIN CHLORIDE POTASSIUM 17, % CHLORIDE POTASSIUM CHLORIDE TOLTERODINE 32, % TARTRATE POTASSIUM CHLORIDE OXYBUTYNIN 32, % CHLORIDE CHLORPROMAZINE HCL ZIPRASIDONE HCL 6, % BENZTROPINE MESYLATE POTASSIUM 69, % CHLORIDE CIPROFLOXACIN HCL TIZANIDINE HCL 38, % DIPHENOXYLATE HCL/ATROP SULF DICYCLOMINE HCL SCOPOLAMINE HYDROBROMIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE 3, % , % , % CMS FFY 2009 Table 2 2

22 Michigan Medicaid Table 2 ProDUR Encounters by Problem Type Problem Drug History # Claims # Alerts Alert % # Denial # Paid Type Alerts Alerts Drug To TAMSULOSIN HCL Used exclusively in men 7, % Gender SX SILDENAFIL CITRATE Used exclusively in men 5, % TADALAFIL Used exclusively in men 2, % MICONAZOLE NITRATE Used exclusively in 10, % 94 0 women MEDROXYPROGESTERONE Used exclusively in 18, % 80 0 ACET women ANASTROZOLE Used exclusively in 3, % women LETROZOLE Used exclusively in 1, % women LUBIPROSTONE Used exclusively in 2, % 68 7 women CLOTRIMAZOLE Used exclusively in 25, % 71 0 women TESTOSTERONE Used exclusively in men 2, % 29 0 CMS FFY 2009 Table 2 3

23 Michigan Medicaid Table 2 ProDUR Encounters by Problem Type Problem Drug History # Claims # Alerts Alert % # Denial # Paid Type Alerts Alerts Drug To DIAZEPAM Drug therapy should be 203,156 20, % 10,271 N/A Geriatric PA BENZTROPINE MESYLATE Drug therapy should be 69,595 4, % 1,129 N/A AMITRIPTYLINE HCL Drug therapy should be 96,345 4, % 640 N/A BUTALB/ACETAMINOPHEN/CA Drug therapy should be 22,663 3, % 870 N/A FFEINE CHLORDIAZEPOXIDE HCL Drug therapy should be 13,067 3, % 1,680 N/A CYCLOBENZAPRINE HCL Drug therapy should be 60,661 3, % 1,955 N/A HYOSCYAMINE SULFATE Drug therapy should be 7,754 1, % 1,206 N/A CLORAZEPATE DIPOTASSIUM Drug therapy should be 5,228 1, % 292 N/A CLOZAPINE Drug therapy should be 32,883 1, % 291 N/A CARISOPRODOL Drug therapy should be 21,616 1, % 1,158 N/A CMS FFY 2009 Table 2 4

24 Michigan Medicaid Table 2 ProDUR Encounters by Problem Type Problem Drug History # Claims # Alerts Alert % # Denial # Paid Type Alerts Alerts Drug To FLUTICASONE/SALMETEROL ALBUTEROL SULFATE 47,833 37, % 11,586 N/A Inferred Dis DC BUDESONIDE ALBUTEROL SULFATE 44,517 17, % 5,753 N/A HALOPERIDOL BENZTROPINE 28,009 12, % 2,528 N/A MESYLATE INSULIN ASPART GLUCAGON,HUMAN 45,502 11, % 3,840 N/A RECOMBINANT FLUTICASONE PROPIONATE ALBUTEROL SULFATE 72,993 10, % 3,254 N/A BUPROPION HCL FLUOXETINE HCL 153,528 9, % 1,433 N/A METFORMIN HCL LISINOPRIL 55,657 8, % 2,658 N/A INSULIN GLUCAGON,HUMAN 49,506 8, % 2,617 N/A GLARGINE,HUM.REC.ANLOG RECOMBINANT IBUPROFEN PRENATAL VIT/FE 191,905 8, % 3,969 N/A FUMARATE/FA BUPROPION HCL GABAPENTIN 153,528 7, % 951 N/A CMS FFY 2009 Table 2 5

25 Michigan Medicaid Table 2 ProDUR Encounters by Problem Type Problem Drug History # Claims # Alerts Alert % # Denial # Paid Type Alerts Alerts Drug To D-METHORPHAN Drug therapy should be 16,293 14, % 14,456 N/A Pediatric HB/PE/CHLORPHENIR PA LAMOTRIGINE Drug therapy should be 137,465 8, % 3,032 N/A ZONISAMIDE Drug therapy should be 14,826 4, % 1,603 N/A AMPHET ASP/AMPHET/D- AMPHET D-METHORPHAN HB/P-EPD HCL/BPM DEXMETHYLPHENIDATE HCL PHENYLEPHRINE HCL/CHLOR- MAL ASPIRIN LISDEXAMFETAMINE DIMESYLATE GUAIFENESIN/D- METHORPHAN HB Drug therapy should be Drug therapy should be Drug therapy should be Drug therapy should be Drug therapy should be Drug therapy should be Drug therapy should be 256,577 4, % 1,823 N/A 3,305 2, % 2,241 N/A 51,851 2, % 1,062 N/A 2,406 1, % 1,991 N/A 207,484 1, % 518 N/A 63,693 1, % 648 N/A 7,258 1, % 1,110 N/A CMS FFY 2009 Table 2 6

26 Michigan Medicaid Table 2 ProDUR Encounters by Problem Type Problem Drug History # Claims # Alerts Alert % # Denial # Paid Type Alerts Alerts Duplicate QUETIAPINE FUMARATE QUETIAPINE 307,229 89, % 18,135 N/A Therapy FUMARATE TD METHYLPHENIDATE HCL METHYLPHENIDATE HCL 370,365 74, % 10,427 N/A HYDROCODONE BIT/ACETAMINOPHEN AMPHET ASP/AMPHET/D- AMPHET HYDROCODONE BIT/ACETAMINOPHEN AMPHET ASP/AMPHET/D- AMPHET 500,818 60, % 45,480 15, ,577 47, % 6,900 N/A ALPRAZOLAM ALPRAZOLAM 586,968 34, % 8,693 N/A RISPERIDONE RISPERIDONE 230,490 32, % 7,037 N/A VENLAFAXINE HCL VENLAFAXINE HCL 91,580 31, % 2,911 N/A FLUOXETINE HCL FLUOXETINE HCL 202,588 30, % 7,690 N/A DULOXETINE HCL DULOXETINE HCL 127,576 28, % 3,312 N/A SERTRALINE HCL SERTRALINE HCL 209,071 28, % 4,514 N/A CMS FFY 2009 Table 2 7

27 Michigan Medicaid Table 2 ProDUR Encounters by Problem Type Problem Drug History # Claims # Alerts Alert % # Denial # Paid Type Alerts Alerts Min Max CYANOCOBALAMIN Geri Max 0.033ML 30,817 21, % 5,151 N/A HD FLUTICASONE PROPIONATE Pedi Max 0.532G 72,993 20, % 10,254 N/A HYDROCODONE Adult Max 5.000EA 500,818 17, % 16,971 N/A BIT/ACETAMINOPHEN FLUTICASONE PROPIONATE Adult Max 0.532G 72,993 15, % 8,551 N/A HYDROCODONE Adult Max 6.000EA 500,818 15, % 10,025 N/A BIT/ACETAMINOPHEN HYDROCODONE Adult Max 8.000EA 500,818 13, % 13,657 N/A BIT/ACETAMINOPHEN ESCITALOPRAM OXALATE Adult Max 1.000EA 149,411 9, % 2,153 N/A VENLAFAXINE HCL Adult Max 1.000EA 91,580 8, % 1,589 N/A PROPOXYPHENE/ACETAMIN Adult Max 6.000EA 56,710 7, % 7,621 N/A OPHEN ALBUTEROL SULFATE Pedi Max 1.080G 284,322 6, % 2,703 N/A CMS FFY 2009 Table 2 8

28 Michigan Medicaid Table 2 ProDUR Encounters by Problem Type Problem Drug History # Claims # Alerts Alert % # Denial # Paid Type Alerts Alerts Too Late AMPHET ASP/AMPHET/D- AMPHET 256,577 93, % 21,067 N/A AMPHET ASP/AMPHET/D- AMPHET LR ALBUTEROL SULFATE ALBUTEROL SULFATE 284,322 51, % 18,947 N/A CLONAZEPAM CLONAZEPAM 323,329 46, % 7,520 N/A SERTRALINE HCL SERTRALINE HCL 209,071 34, % 5,999 N/A FLUOXETINE HCL FLUOXETINE HCL 202,588 32, % 5,389 N/A TRAZODONE HCL TRAZODONE HCL 175,278 28, % 4,117 N/A GABAPENTIN GABAPENTIN 176,416 27, % 3,530 N/A DIVALPROEX SODIUM DIVALPROEX SODIUM 178,133 27, % 5,228 N/A BUPROPION HCL BUPROPION HCL 153,528 26, % 4,269 N/A ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 149,411 25, % 4,334 N/A CMS FFY 2009 Table 2 9

29 Michigan Medicaid Table 2 ProDUR Encounters by Problem Type Problem Drug History # Claims # Alerts Alert % # Denial # Paid Type Alerts Alerts Too Soon ALPRAZOLAM ALPRAZOLAM 586,968 50, % 46,745 3,861 Clinical ER HYDROCODONE HYDROCODONE 500,818 42, % 40,538 2,122 BIT/ACETAMINOPHEN BIT/ACETAMINOPHEN QUETIAPINE FUMARATE QUETIAPINE 307,229 39, % 38,022 1,480 FUMARATE CLONAZEPAM CLONAZEPAM 323,329 29, % 26,894 2,745 LORAZEPAM LORAZEPAM 291,235 28, % 25,444 2,668 RISPERIDONE RISPERIDONE 230,490 26, % 25,338 1,264 ARIPIPRAZOLE ARIPIPRAZOLE 180,756 20, % 20, ASPIRIN ASPIRIN 207,484 13, % 13, LORATADINE LORATADINE 238,608 12, % 12, DIAZEPAM DIAZEPAM 203,156 12, % 11, CMS FFY 2009 Table 2 10

30 Michigan Medicaid Program Table 3 Cost Avoidance Calculations Cost Avoidance Calculations: Paid Claims Reversed and Not Resubmitted Denied Claims Not Resubmitted $13,685,205* + $153,199,645 = $153,199,645 Calculation Details: *Paid Claims Cost Avoidance Count Amount Paid Claims: reversed 240,740 $35,562,130 Paid claims: Resubmitted (114,130) ($21,876,924) (within 72 hours) Total Calculated Cost Avoidance from Paid Claims 126,610 $13,685,205* * Paid Claims Cost Avoidance is calculated by taking the paid dollar amount of claims with a ProDUR message that had paid, but were subsequently reversed and subtracting the paid amount the claims resubmitted within 72 hours. Denied Claims Cost Avoidance Count Amount Denied Claims 1,709,864 $223,996,902 Resubmitted claims (717,954) ($70,797,257) (within calendar month in same drug class) Total Calculated Cost Avoidance from Denied Claims 991,910 $153,199,645 Denied Claims Cost Avoidance is calculated by taking the submitted dollar value of the claims that were initially denied and had a ProDUR message and subtracting any of those claims that were then resubmitted within the same calendar month and then paid. CMS FFY 09 Table 3

31 Michigan Medicaid Table 4 RetroDUR Lettering FFY 2009 Number of Profiles Reviewed Number of letters Sent Number of responses received Response % Month Topic Oct 08 Diabetics without Aspirin or Plavix % Nov 08 Diabetics without Aspirin or Plavix % Dec 08 Underutilization of inhaled corticosteroids % Jan 09 Underutilization of inhaled corticosteroids % Feb 09 Underutilization of inhaled corticosteroids % Mar 09 Polypharmacy - behavioral health meds % Duplication of Suboxone with Narcotics % Apr 09 Methadone use % May 09 Underutilization of statin medications % Jun 09 Underutilization of statin medications % Jul 09 Proton Pump Inhibitor's with H2RA's or Plavix % Aug 09 Pulmicort nebulized BID or more % Sep 09 Triptans without Migraine Controller medications % Totals % CMS FFY 2009 Table 4

32 Michigan Medicaid Program Table 5 Population Statistics FFY 2009 Percent Percent Percent Percent Avg. Amt. Age Drug Total Ingredient Ingredient Total # Total Paid Member Member Paid Quantity Quantity Cost Cost Of Claims Claims Amount Months Months Per Claim Utilization ,864, % $136,798, % 1,231, % $114,243,443 1,014, % $ ,329, % $112,338, % 854, % $93,359, , % $ ,611, % $170,185, % 2,047, % $156,219,872 1,787, % $ ,999, % $203,136, % 2,944, % $193,136,748 2,725, % $ ,177, % $3,749, % 507, % $4,017, , % $7.92 Totals 544,982, % $626,208, % 7,585, % $560,976,877 6,734, % $82.55 CMS FFY 2009 Table 5

33 Michigan Medicaid Program Table 6 Top 15 Therapeutic Classes By Total Cost for FFY 2009 Age 0-12 Age Age Age Age > 65 Cl* Total Total Cl Total Total Cl Total Total Cl Total Total Cl Total Total Cost Count Cost Count Cost Count Cost Count Cost Count 99 $20,706, ,591 7 $27,529, ,697 7 $61,301, ,717 7 $81,454, ,169 7 $562, ,127 7 $20,279, , $18,550, , $21,900, , $21,315, , $324, , $13,235, , $8,000, , $16,626, , $21,240, ,519 1 $278, , $9,102, , $6,982, , $14,295, , $18,807, , $272, , $8,711, , $6,284, , $11,106, , $7,370, , $232, , $4,972, , $4,316, , $3,687, , $5,196, , $215, , $4,773, , $4,029, , $3,327, , $4,225, , $188, , $4,383, , $3,138, , $2,298, , $3,999, , $159, , $3,609, , $2,369, , $2,000, , $3,295, , $141, , $3,602, , $1,185, ,769 1 $1,703, ,254 1 $3,081, ,030 # 6 $140, , $2,409, ,950 1 $966, , $1,312, , $2,809, , $133, ,380 1 $2,108, , $890, , $1,229, , $1,972, , $123, , $1,512, , $818, , $1,068, , $1,498, , $122, , $1,441, $703, , $1,033, , $1,376, , $117, , $1,219, , $647, $1,015, , $1,254, , $112, ,891 * Class descriptions found in Appendix A CMS FFY 2009 Table 6

34 Michigan Medicaid Program Table 7 Top 30 New Drugs by Total Cost for FFY 2009 Class Generic Name Brand Dosage FFY 2008 Strength Name Form Cost 7 QUETIAPINE FUMARATE 150MG SEROQUEL XR TAB.SR 24H $329, QUETIAPINE FUMARATE 50 MG SEROQUEL XR TAB.SR 24H $294, DARUNAVIR ETHANOLATE 400 MG PREZISTA TABLET $137, RUFINAMIDE 400 MG BANZEL TABLET $44, RUFINAMIDE 200 MG BANZEL TABLET $38, LEVETIRACETAM 750MG KEPPRA XR TAB.SR 24H $31, TETRABENAZINE 12.5MG XENAZINE TABLET $18, GRANISETRON 3.1MG/24HR SANCUSO PATCH TDWK $10, LACOSAMIDE 100MG VIMPAT TABLET $10, LACOSAMIDE 50 MG VIMPAT TABLET $10, PLERIXAFOR 24MG/1.2ML MOZOBIL VIAL $6, TETRABENAZINE 25 MG XENAZINE TABLET $5, INSULIN GLULISINE 100/ML APIDRA SOLOSTAR INSULN PEN $4, SOMATROPIN 10MG/1.5ML OMNITROPE CARTRIDGE $4, LACOSAMIDE 150MG VIMPAT TABLET $2, LAMOTRIGINE 200 MG LAMICTAL XR TAB ER 24 $1, MORPHINE SULFATE 75MG AVINZA CPMP 24HR $1, CERTOLIZUMAB PEGOL 400MG/2ML CIMZIA SYRINGEKIT $1, DAPSONE 5% ACZONE GEL (GM) $1, PNV W-CA #40/IRON FUM/FA CMB#1 27MG PRENATE ELITE TABLET $1, LAMOTRIGINE 100MG LAMICTAL ODT TAB RAPDIS $1, MESALAMINE 0.375G APRISO CAP.SR 24H $1, LACOSAMIDE 200 MG VIMPAT TABLET $1, MILNACIPRAN HCL 50 MG SAVELLA TABLET $1, FEBUXOSTAT 40 MG ULORIC TABLET $1, PNV53/IRON B-G SUC-P/FA/OMEGA RENATE DHA COMBO. PKG $ FEBUXOSTAT 80MG ULORIC TABLET $ ARMODAFINIL 150MG NUVIGIL TABLET $ FENOFIBRIC ACID (CHOLINE) 135MG TRILIPIX CAPSULE DR $ CROTAMITON 10% EURAX SUSPENSION $ Total FFY 2009 Top 30 New Product Costs : $966, Total FFY 2009 All New Product Costs : $973, Percent Total Program Costs for FFY 2009 ( $560,976,877.41): 0.17% * Class descriptions located in Appendix A CMS FFY 2009 Table 7

35 APPENDIX A First Data Bank Therapeutic Class Descriptions 1 Anti-Ulcer/Other GI Agents 51 Glucocorticoids 2 Emetics 52 Mineralocorticoids 3 Antidiarrheal Agents 53 Aldosterone Antagonists 4 Antispasmodics/Anticholinergics 54 Antidotes 5 Bile Therapy 55 Thyroid Preps 6 Laxatives 56 Antithyroid Preps 7 Ataractics/Tranquilizers 57 Iodine Therapy 8 Muscle Relaxants 58 Diabetic Therapy 9 Antiparkinson 59 Anabolics 10 CNS Stimulants 60 Androgens 11 Psychostimulants/Antidepressants 61 Estrogens 12 Amphetamines 62 Progesterone 13 Other Anti-obesity Agents 63 Oral Contraceptives 14 Antihistamines 64 Other Hormones 15 Bronchial Dilators 65 Lipotropics 16 Cough Preps/Expectorants 66 Cholesterol Reducers 17 Cold and Cough Agents 67 Digestants 18 Adrenergics 68 Protein Lysates 19 Topical Nasal and Otic Agents 69 Enzymes 20 Ophthalmic Agents 70 Rauwolfias 21 Tetracyclines 71 Other Hypotensives 22 Penicillins 72 Vasodilators, Coronary 23 Streptomycins 73 Vasodilators, Peripheral 24 Sulfonamides 74 Digitalis Preps. 25 Erythromycins 75 Xanthine Derivatives 26 Cephalosporins 76 Other Cardiovascular Agents 27 Other Antibiotics 77 Anticoagulants 28 Urinary Antibacterials 78 Hemostatics 29 Chloramphenicol 79 Diuretics 30 Antineoplastics 80 Fat Soluble Vitamins 31 Antiparasitics 81 Water Soluble Vitamins 32 Antimalarials 82 Multivitamins 33 Antivirals 83 Folic Acid Preps. 34 TB Preparations 84 B Complex w/vitamin C Agents 35 Trimethoprim 85 Vitamin K Agents 36 Topical Contraceptives 86 Infant Formulas 37 Vaginal Cleansers 87 Electrolytes & Nutrients 38 Antibacterials and Antiseptics 88 Hematinics 39 Diagnostics 89 Allergens 40 Narcotic Analgesics 90 Biologicals Appendix A