TennCare Drug Utilization Review (DUR) Board Minutes

Transcription

1 State of Tennessee Department of Finance and Administration Bureau of TennCare 310 Great Circle Road Nashville, TN TennCare Drug Utilization Review (DUR) Board Minutes September 11, 2012 In attendance: DUR Board: David Shepard, PharmD, Michael Keny, DPh, Shelton Lacy, APRN, Denise Barker, PharmD, Richard Randolph, PharmD Bureau of TennCare: David Collier, MD, Ray McIntire, DPh, Michael Polson, PharmD, MS, Bryan Leibowitz, PharmD SXC Health Solutions: Toie Alston, PharmD, Bill Hudson, PharmD Introduction: The meeting was called to order by Dr. Alston, who welcomed everyone to the TennCare Drug Utilization Review (DUR) Board meeting. DUR Board Appointees, Bureau of TennCare Representatives, and SXC Health Solutions, Inc. Representatives introduced themselves. Review of minutes: The Board was asked to review minutes from June 5, 2012 meeting. A motion was made by Dr. Randolph, seconded by Dr. Collier to approve the minutes as presented. Minutes approved with no changes. Dr. Collier gave the following TennCare Medical update: TennCare Standard Spend Down: The 5 th round of enrollment opportunity is set for September 13, 2012, beginning at 6 PM CST. Interested applicants may call to request an application. Operators will close the phone lines once 2,500 applicant calls have been received. In the past, this cut-off limit has been reached approximately 1 hour after the initial opening of the phone lines. o SSD serves a limited number of people who are not otherwise eligible for Medicaid, but are: 21 and over, not pregnant, US citizen or legal resident, Tennessee resident, not incarcerated, or 65 years of age or older, blind, disabled (as determined by social security), or Caretaker relative of a Medicaid eligible child and who have enough unreimbursed medical bills to allow them to spend down their income to the State s Medically Needy Income Standard (MNIS). ICD 10 Implementation: Last week, CMS (Centers for Medicare & Medicaid Services) announced the final rule that delays the ICD-10 implementation compliance date for 1 year, which sets the date to October 1,

2 The Electronic Health Record (EHR) Provider Incentive Program Update: Tennessee is doing quite well with the incentive program. In year one, 2,097 eligible providers (EP) were paid a total of $44,228,340 with $586,500 paid to 69 eligible providers in year two. Eligible hospitals (EH) that participated in the incentive program for year one, a total of $45,764,040 was distributed to 67 eligible hospitals (EH). In the second year $1,283,296 was paid to 5 eligible hospitals. TennCare Pharmacy Update provided by Dr. Collier: TennCare s Pharmacy Benefit Manager (PBM): TennCare's Pharmacy Benefits Manager, SXC Health Solutions, Inc. has merged with Catalyst Health Solutions to become Catamaran. o This company merge will not affect TennCare s current contract, but the merge will affect addresses of former SXC employees. Pharmacy Benefit Manager RFP (Request for Proposal): The pharmacy benefit manager RFP has been released for bids, as the current contract expires May 31, The state anticipates that the new contract will be signed by November Implementation and/or transition will begin in December 2012, based on who will be awarded the contract. The Go-live date for the new contract is set for June 1, Dr. Collier presented TennCare s Neonatal Abstinence Syndrome Project: There was an increase in the incidence rate of neonatal abstinence syndrome (NAS) among TennCare recipients from CY 2008 through CY The trend appears to have plateaued in CY 2011 although the 2011 numbers are preliminary. The number of live births used in the denominator for CY 2011 was estimated based on the average birth rate for TennCare enrollees in the prior three years. The official number of births was used in all other years. NAS is a condition that occurs when the mother is receiving narcotics or other addictive medications. The numbers exclude fetal alcohol syndrome. NAS infants are at increased risk of low birth weight and longer hospitalization. Across the four year period at least 82% of NAS children were born to mothers on TennCare at the time of delivery, meaning less than 18% of TennCare infants with NAS obtained eligibility at birth or received eligibility some time during the first year of life. TennCare ends up being responsible for a large percentage of these children. Slightly over half, 51%, of moms with NAS children had TennCare eligibility for 9 or more months prior to delivery. The agency has an opportunity to maybe intervene here. The majority of NAS cases are in East TN, and the county with the highest incidence is Campbell County. The regional pattern is similar to the pattern seen with TennCare enrollee emergency department visits for prescription drug abuse related overdoses, where rates are considerably higher in East and Middle Tennessee than in the western part of the state. Nearly 85% of the NAS mothers are between the ages of 21 and % of the women reside in east TN and 93% of all mothers with an NAS infant treated by TennCare were White Non-Hispanic. Approximately 40,000 live births are paid for by TennCare each year, and on average each child costs $7,285. $4,347 is the average cost per child for TennCare non-low-birth-weight infant, $32,194 for low-birth-weight infant, and $40,931 for a NAS infant. The average cost of care for NAS infants in the first year of life is 2

3 more than 9 times higher than the average cost of care for normal birth weight infants. Low birth weight is defined as less than 2,500 grams. A high percentage of NAS infants end up in DCS custody within one year of their birth. Infants born with NAS are 14 times more likely to be in DCS custody during the first year of life as compared with other TennCare infants. o Dr. Shepard asked if TennCare eligibility for this particular class is any different than Kentucky eligibility. o Dr. Collier replied it s a mandatory eligibility so Kentucky eligibility should be similar. o Dr. Polson stated that the map looks the same for any disease prevalence. On average, women had 1.5 unique prescribers of narcotics in a one year period, with the maximum being 14 for one enrollee. About 31% of women with NAS babies who received narcotics paid for by TennCare appeared to be receiving treatment for opioid dependence. Approximately 80% of women of child bearing age (15-44) prescribed a narcotic aren t prescribed any form of contraceptive. This is an area to focus on- to decrease that percentage, especially in those women who are treated for narcotic dependence. What are some things we can do to decrease this number? Perhaps DUR activities similar to ACE-Inhibitor activity, add contraceptive counseling to PA forms for Suboxone and narcotics. o Dr. Alston recommended strengthening the pregnancy edit surrounding those medications. o Dr. Collier stated TennCare is working on a way to find out as early as possible when a woman becomes pregnant. Historically OBs file a global fee and submit their fee after delivery. o Dr. Hudson asked that if edits were built around use of prenatal vitamins, would that deter prenatal narcotic use. o Dr. McIntire stated that prenatal vitamins with an opioid could prompt a letter to the physician possibly informing them to report the pregnancy to TennCare. o Dr. Collier stated the copays are waived if the enrollee is pregnant therefore there is some incentive for the enrollee. There s a good chance to make a difference with prescriber education. Dr. McIntire reviewed DUR Board Responsibilities and CMS Requirements: Dr. McIntire supplied the Board with a handout outlining the Board responsibilities. Currently the Board is doing well in regards to retrospective drug review surrounding the use of predetermined standard edits. Keying in on the educational program, our program currently involves a lot of letters. It consists of 2400 provider analysis letters per quarter and 800 member profile reviews per month. The guidelines state the programs must include: o Dissemination of information to physicians and pharmacies in the state concerning the duties and powers of the DUR Board. This is something that probably needs to be sent out to pharmacies and physician telling them about the DUR Board. o Written, oral, electronic reminders containing patient specific or drug specific information and suggested changes in prescribing or dispensing 3

4 practices. This is what we are currently doing today with the letter campaign. o Face to face discussion, with follow up discussions when necessary, between health care professionals experts in appropriate drug therapy and selected prescribers and pharmacists who have been targeted for educational intervention on optimal prescribing or pharmacy care practices. This is an area that needs improvement. o Intensified review or monitoring of selected prescribers or dispensers. The DUR Board should perform the following activities: o Review and make recommendations on predetermined standards submitted to it by the Medicaid agency or the agency s contractor. o Evaluate the use of the predetermined standards, including assessing the operational effects of the predetermined standards in use The Medicaid agency role is to act upon the recommendations. The DUR Board should perform the following activities: o Review and make recommendations on predetermined standards submitted to it by the Medicaid agency or the agency s contractor. o Make recommendations to the Medicaid agency or the agency s contractor concerning modifications or elimination of existing predetermined standards or the addition of new ones. Going forward maybe the Board should review actual edits within classes to determine if they are appropriate today. For example today TennCare max dose is set at 225% of the max dose for every category. There may be categories that the Board fells need to be set at a set higher or lower maximum dose. The DUR Board may need to visit this in the future. The DUR Board must perform the following activities: o Identify and develop educational topics if education of practitioners on common drug therapy problems is needed to improve prescribing or dispensing practices o Make recommendations as to which mix of the inventions set forth would most likely effectively lead to improvement in the quality of drug therapy The Medicaid agency should: o Apply predetermined standards to drug claims data to generate reports that provide the basis for retrospective education and interventions and furnish those reports to the Board o Carry out the educational programs and interventions specified by the Board Old Business from June 5, 2012 Blocked Prescriber Appeal- Dr. McIntire presented the Board with original claim information including meeting minutes pertaining to the provider, claim data since the review, and the attorney argument. There was a basic concern with the number of high dose short-acting opioids being prescribed. There are not many claims for 2012 and still not seeing many long acting opioids. There was some improvement in prescribing habits. This nurse practitioner is no longer writing for methadone. The ratio of CII to CIII is now 3.5:1. The argument doesn t address why this provider is a high prescriber other than this provider operates a pain clinic so this person shouldn t be judged against other prescribers. The statement that in addition to one pain management specialty, the 4

5 next contiguous specialty is proximately located more than forty miles away is incorrect. There are 3 registered pain management clinics in this city. o Dr. Shepard asked can a nurse practitioner have a separate contract from the supervising physician. o Dr. McIntire stated the supervising physician retired in November. Prescriber 6, whom was blocked, was the nurse practitioner s supervising physician. This nurse practitioner licensure verification shows a Kentucky address and no supervising physician. This practitioner doesn t have a Medicaid number. o Dr. Shepard mentioned that legislature is really looking at controlled substance utilization and controlled substance clinics, pain clinics. If the DUR Board doesn t stand up to its decision on this particular issue, the Board might be seen as not doing its job. Once a decision has been made we should stick to it. o Dr. Collier asked if the legal team had any issues regarding the letter. o Dr. McIntire replied at first it wasn t sure if this was considered an appeal. They thought we had to consider an appeal. A motion was made by Dr. Shepard, seconded by Ms. Shelton to continue to move forward with the blocking of prescriber 4. The Board approved the motion. Standing Business: Dr. Alston Presented TennCare Drug Utilization Data: o TennCare population remains stable at approximately 1.2 million members. Utilizing children have decreased 11.83% over 2Q11. The average payment paid per utilizing children has increased 2.8% and the average amount paid per eligible enrollee increased 4%. The average payment per claim is holding firm at $ o Currently % of all claims processed are for generic drugs. Overall generic utilization continues to increase keeping payment amount down. The average cost of branded agents increased, however utilization is down. Branded agents account for a small percentage of total prescription volume therefore the cost doesn t have a huge impact on the total payment amount. o Six classes listed in the Top Therapeutic Class by Payment Amount are also in the Top Therapeutic Class by Claim Volume which includes: atypical antipsychotics, ADHD, narcotic analgesics, anticonvulsants, sympathomimetics, and proton pump inhibitors. Atypical Antipsychotics class decreased 18.08%. Quetiapine payment amount decreased 68.7%, however it still remains in the top 10 drugs by payment amount for adults. ADHD payment increased 17.94% which correlates to the fact that 3 of the top 10 drugs by payment amount are ADHD agents. Adult ADHD utilization increased 7.75%. o Buprenorphine is a new drug topping the drug inferred diagnosis pregnancy edit. Buprenorphine is classified as FDA pregnancy category risk C, and this edit receives a message at point of sale. All severity level 1 and 2 drug gender edits, with the exception of tamsulosin and nevirapine, receive a hard reject at point of sale. Of the prenatal vitamins that received a hard reject, 22.6% went on to pay once the pharmacist corrected the member sex on the claim. In 1Q12, the tamsulosin gender edit was programed as a hard reject. During this quarter, there were 433 edits of 5

6 which 7.2% paid. In 2Q12, the edit was converted to a soft reject. During this quarter, there were 410 edits of which 54.9% paid. Dr. Alston presented 4th Quarter RetroDUR and Provider Analysis Activities: Dr. Alston asked the Board if they had any recommendation for future DUR activities. All activity letters were provided to the Board members. o Singulair Utilization- For April the Singulair utilization activity from last quarter was continued. This activity targeted patients on Singulair without a first-line agent for allergic rhinitis in claim history. o Insomnia Therapy- This activity focused on patients who received 3 or more months of consecutive sedative hypnotic treatment. o Overutilization of SABA- The activity identified patients who received more than 1 albuterol inhaler per month for a 3 month time frame with no pharmacy claims in the past 3 months for an inhaled corticosteroid or an alternative long-term controller medication. 1,500 patient profiles were reviewed and 889 letters were sent to prescribers, addressing 1,343 patients. o Top Narcotic Prescribers-- The top 126 narcotic prescribers were lettered. o Short Acting Narcotic Initiative-- A total of 2,617 prescribers were found to meet the criteria during the Short Acting Narcotic initiative analysis, from that total, 800 prescribers were lettered. o Potentially Inappropriate Use of Medications in Older Adults- This activity concentrated specifically on the use of the following medication in older adults: antimuscarinics, antihistamines, TCA s, NSAIDs, and skeletal muscle relaxants. 2,365 prescribers were lettered. Dr. Alston proposed new RetroDUR and Provider Analysis Activities: o Lithium Treatment- Activity will focus on precautions associated with lithium treatment including: drugs that affect pharmacokinetics of lithium, use in women of childbearing age and drug interactions (including ACEIs ARB s, NSAIDs, certain CCB s and diuretics). o Poly-Pharmacy- For this review Poly-pharmacy is defined as enrollees with at least 14 prescriptions, written by at least 4 different prescribers, and filled by at least 3 different pharmacies within a 6-month time frame. This activity allows reviewers to look for patients who are chronically at risk for inappropriate utilization, doctor/ pharmacy shopping, therapeutic duplications, and adults utilizing their children s benefits (ordinary adult medications under a child s profile). o Treatment of Type II Diabetes in Children and Bisphosphonate Therapy for Osteoporosis- Both of these will be educational pieces focusing on appropriate therapy and duration of treatment. o Dr. McIntire stated that in the future Catamaran will work on providing more outcome data and face-to-face interviews with prescribers. Pregnancy with opioids is a concern that will be added here. If anyone has ideas outside of the meeting please call. o Dr. Barker stated the letter campaign isn t getting the job done. o Dr. Hudson asked if the letters aren t cutting it what are some other options to reach such a large scale of people dispersed throughout the state. Door to door activity isn t easily accomplished with such a large area to cover. o Dr. Barker stated that with MTM she has found that if you fax a form you get a negative response; however if you call and have a conversation you get better results. 6

7 o Dr. Hudson asked would it be of benefit to call the prescribers who fail to submit a response form or the outliers. o Dr. Barker stated it would be beneficial to contact the outlying prescribers. Dr. McIntire presented Pharmacy Lock-In Program: o This is currently a manual process and the focus is mainly on one criteria. The criteria look within a 3 month period for 3 controlled substances, 3 pharmacies, and 3 prescribers. More emphasis has been given to carefully identify the prescribers as there are multiple prescribers in many practices. This may be lowering the numbers. o 50 enrollees that are currently locked in are Re-Reviewed every month for potential escalation or removal of the Lock-In edit. Results from 2Q12 Re- Review results: Escalate to PA Status: 23 Remove Lock-In: 37 Remain Locked-In: 75 OIG/MCO/ Mbr Svc Referrals: 5 Remain on PA status: 14 o For Re-Review, both cash and TennCare claims are reviewed with the exception of drugs that are not covered by TennCare (e.g., benzodiazepines for adults). The enrollee can be escalated to PA Only status, where the enrollee needs a PA for every fill of every controlled substance. We have found that in some cases, the prescriber does not make PA requests, and the enrollee ends up paying cash for all the controlled substances. o Patient may be removed from PA Only status if they have utilized only 1 physician, 1 pharmacy, and no cash prescriptions for medications covered by TennCare for a six-month period. o Locked-In recipients are allowed 1 pharmacy change per calendar year Dr. McIntire presented PA Only Status Outcomes Analysis: o Purpose of the escalation to PA Only Status is to further restrict a TennCare enrollee, who has continued to use multiple pharmacies and providers while being subject to the Lock-In edit. It is also reserved for those members who have been convicted of TennCare fraud. Enrollees convicted of TennCare fraud are not eligible for Re-Review and will remain on PA Only Status as long as they are eligible for TennCare. o The goal is to influence enrollee behavior with additional roadblocks and restriction of controlled substances, hopefully reducing the number of pharmacy and prescriber providers they use. o Since January 2010, 184 Enrollees have been escalated to PA Only Status, with 89 escalations in In 2011, 56 of these enrollees were found to have six months of eligibility pre- and post-escalation. All claims were examined, both paid and rejected for the 56 enrollees for six months pre- and post-escalation. Claims from 3 of the 56 enrollees were excluded, for having noncontrolled specialty drug claims, which were different in the preand post-escalation periods, to avoid skewing the results. Pre-escalation the paid controlled prescription total dollar amount was $50,368, and the post-escalation amount was $30,933. The controlled prescription count decreased 67%. There was an approximate $20,000 savings. Overall there were fewer physicians and pharmacies being used. 7

8 Dr. McIntire discussed Controlled Substance Prescribing Quality Metrics: In the past TennCare has used a Top Narcotic Prescribers list, for identifying highvolume, and high-percentage narcotic analgesic prescribers. o Problem is that the list only measured quantity and percent of narcotics prescribed. The measurement was primarily about volume, and not about quality or standards of care. Top prescribers on the list were often Suboxone prescribers, as they have a high percentage of overall opioid prescribing. o At the last DUR Board meeting different metrics were used to identify outliers amongst the non-participating prescribers within the Top 100 Narcotic Prescribers. It was felt that the result showed a better picture of the prescribing habits of the prescribers. o Overall goal is to use new quality metrics to identify prescribers who are outliers, and to analyze all prescribers, whether in-network or nonparticipating. Are there other metrics the Board would like to see included? The proposed metrics include: Include all narcotics and stimulants Eliminate Suboxone from the metrics Total number of submitted claims, paid & RJ Total # and % of controlled substances Total # and % of narcotic analgesics # of short-acting and long-acting opiates # of SAO combinations vs. SAO pure opiate Ratio of SAO vs. LAO # of C-II, C-III and C-IV o The average distance from the state and the patient was another metric to include however the prescriber address data isn t reliable. o All metrics are weighted, according to a volume category therefore volume has some weight, but quality is also involved. o Ms. Lacy stated that we should monitor for those with neuropathic medications in combination with opioids. o Dr. McIntire stated the list will be evaluated and updated quarterly. Dr. Alston presented DUR Intervention outcomes: These are some intervention outcomes that may be submitted to CMS. This will give some idea as to how well the physicians are responding to the DUR letters. These activities were developed primarily to focus on appropriate utilization: o Drug Disease Edit: Stimulant/Suboxone or Subutex - The DUR board approved the drug disease edit for Suboxone/ Subutex. This edit was setup to hard reject at the point of sale for members receiving Suboxone or Subutex and a concurrent prescription for a stimulant. Over a 3-month period post implementation there were 21 alerts which resulted in ~$1, savings. This edit doesn t apply to all stimulates just those with labeled contraindication which include methylphenidate, methamphetamine, Vyvanse, dextroamphetamine, Nuvigil, amphetamine salts, and dexmethylphenidate. o Maximum Dose Edit: Gabapentin 3600mg/day- This activity focused on gabapentin potential for abuse and the max dose edit which was set at 3,600mg per day. Providers were encouraged to review all patients receiving gabapentin and if applicable make necessary changes. The endpoint involves patients who were taking greater than 3,600mg/day and 8

9 retained their active coverage throughout period being evaluated. The evaluated period was 3 months post quantity limit implementation. Out of 141 members 17% continued their existing dose, 62% decreased the dosage or changed medication, and 21% discontinued therapy. Therapy change review looked for any drug to treat Postherpetic neuralgia, seizures or restless legs syndrome (RLS). Cost saving over a 3-month period was ~$6, o Maximum Dose Edit: Simvastatin 80mg- This correspondence reviewed action that the FDA took on simvastatin, which included dosage restrictions, limitation on the use of the 80mg dose, and the addition of new contraindications to simvastatin s label. The endpoints include all original members who had continuous coverage 3-months pre- and post-activity, which involved 3,656 enrollees. 36% continued same statin regimen, 40% changed lipid therapy or decreased simvastatin dose, and 24% discontinued lipid therapy. Cost saving for this activity was an added expense of $49, In order for some patients to meet lipid goals, they were switched to another high potency, more costly agent such as Lipitor. o Dr. Alston suggested that follow up review be done when activities are recommending that therapy be stopped or switched to make sure there are no breaks in treatment. Dr. Polson discussed Psychotropic Medication Use in Children: CMS and other Agencies advocating for children sponsored a summit to focus on the use of psychotropic medication specifically in foster children. One idea at the meeting was to initiate DUR activities in regards to this matter to help insure appropriate treatment. Nationally, Tennessee is doing well but there s room for improvement. Meeting was adjourned at 11:45pm Next DUR Board Meeting scheduled for November 13,