Improving Mental Health Care: A Case Study

Improving Mental Health Care: A Case Study

Why Improve Mental Health Care? Because the prevalence and costs of mental health problems are increasing in America despite the high prescribing of psychotropic drugs. Depression is the number one risk factor impacting medical spend per multiple studies latest study reported a 48% increase for depression. Mental Health America reported: Depression now affects more than 21 million American children and adults annually Depression is the leading cause of disability in the United States for individuals ages 15 to 44 2

Depression Has an Impact on Mean Health Scores More Than Other Chronic Conditions Depression had the largest effect on worsening mean health scores Mean Health Score (0-100) 100 90 80 70 60 50 0 *P<.0001 * * * 1 2 3 4 80 80 79 79 Depression Only * * 73 P<.01 1 2 3 67 66 65 N=245,404 * Depressed respondents had lowest mean score among all chronic conditions (P<.0001) Depressed respondents with another chronic condition had lower mean health scores than respondents with the chronic condition alone (P<.01) 4 59 One Chronic Condition Depression + One Chronic Condition 90.6 = No Chronic Condition Conditions 1. Asthma 2. Angina 3. Arthritis 4. Diabetes Moussavi S, et al. Lancet. 2007;370:851-858. 3

U.S. Disability Claims for Mental Health Millions of adults, 18 to 66 years old Source: U.S. Social Security Administration Reports, 1987 2010 4

Top 5 Therapeutic Classes by Prescription DISPENSED PRESCRIPTIONS (Millions) 2011 2010 2009 2008 2007 TOTAL US MARKET 4,024 3,993 3,949 3,866 3,825 1 Antidepressants 264 254 247 241 237 2 Lipid Regulators 260 260 254 242 233 3 Narcotic Analgesics 238 244 241 239 231 4 Antidiabetes 173 172 169 166 165 5 Ace Inhibitors 164 168 166 163 159 Source: IMS Health, National Prescription Audit, Dec 2011 Updated February 23, 2012 The annual dollar spend for antidepressants in 2011 was over $11B 5

The Paradox of Antidepressants and other Psychotropic Drugs These drugs have been documented to help individuals dealing with mental health conditions These drugs have been documented to harm individuals dealing with mental health conditions Which statement is valid? 6

Effects of the Drugs Steven Hyman, M.D., as Director for the National Institute of Mental Health (NIMH), wrote a summary of the research on psychotropic drugs in which he stated, (Psychotropic drugs) create perturbations in neurotransmitter functions The chronic administration of the drug then causes substantial and long lasting alterations in neural function After a few weeks, he concluded, the person s brain is functioning in a manner that is qualitatively as well as quantitatively different from the normal state So instead of correcting a chemical imbalance (as claimed), the drugs create a chemical imbalance. 7

What do the Studies Report? Of 74 (short term) studies on depression registered with the FDA, 38 reported a positive outcome and 36 reported a negative outcome Longer term studies report up to 80% of patients maintained on an antidepressant suffer a recurrence of symptoms, and once that initial treatment response is lost, continued efforts to treat the patient with antidepressants frequently result in poor response and the rise of treatment resistant depression * *Source: Rif El Mallakh, M.D., Director, Mood Disorders Clinical and Research Program, University of Louisville School of Medicine. 8

The STAR*D Trial Confirms: Depression Runs a Chronic Course Today Findings from the National Institute of Mental Health s STAR*D study, which was the largest study of depression ever conducted: 40% 20% 0% 38% Remitted During Study 3% Remained in Remission 38% of the patients properly enrolled in the trial remitted during one of the four stages of drug treatment. Only 3% of the patients remitted and then stayed well throughout the 12 month follow up (108 of 4,041.) The remaining patients either failed to remit, relapsed during the follow up, or dropped out. Source: Pigott, E. Efficacy and effectiveness of antidepressants. Psychother Psychosom 79 (2010):267 79. 9

What is the Answer? It depends on how psychotropic drugs are being prescribed When used appropriately and judiciously, these medications can enhance the quality of life for some, particularly short term There is convincing (and growing) evidence that these drugs worsen the long term course of depression for a number of individuals The treatment and risks of psychotropic drugs need to be managed are they? 10

It Starts with Who s Writing the Scripts 100% 75% 50% 25% 0% Prescriptions by Non Psychiatrist 79% 87% Antidepressants Anxiolytics 79% of prescriptions for antidepressants were written by non psychiatrists 87% of prescriptions for anxiolytics were written by non psychiatrists Open Minds, September 24, 2009, reporting on a study in which researchers reviewed 472,173 prescriptions filled between August 2006 and July 2007 from the IMS National Prescription Audit Plus database. Does this produce a positive course of care? 11

What the Research is Reporting A significant proportion of individuals with behavioral health problems are treated exclusively in the general medical setting, which has become the de facto mental healthcare system significant quality problems have been found with general medical providers screening, treatment, and monitoring practices. An Employer s Guide To Behavioral Health Services, released by the National Business Group on Health, December 2005. More Americans are being prescribed multiple psychiatric medications for use at the same time, but most people diagnosed with recent depression don t get adequate treatment, according to two independent studies published Monday. Studies: Mental Ills Are Often Overtreated Or Undertreated, Wall Street Journal, January 5, 2010. 12

Supporting Study Only 12.7% of individuals seeking mental health treatment in the general medical setting received minimally adequate care compared to 43.9% of patients treated in the specialty mental health sector. 50% 25% 0% Minimally Adequate Care 12.7% General Medical Setting 43.9% Specialty Mental Health Sector Percent of patients receiving minimally adequate care in the primary care setting Percent of patients receiving minimally adequate care in the specialty mental health sector National Co morbidity Survey Replication. Archives of General Psychiatry. 2005 (Also reported in the Interim Final Rules for the Federal Mental Health Parity Act) 13

The Next Wave With many of the top selling antidepressants coming off patent, stronger and more costly antipsychotic drugs are now being marketed as a magic bullet for depression through physician education and direct consumer advertising, i.e. Abilify and Seroquel, which have potentially serious side effects. Increased Blood Sugar Antipsychotic Side Effects Weight Gain Elevated Lipids & Cholesterol Potentially Irreversible Movement Disorder 14

The Drug Pipeline Very aggressive physician education drives the high prescribing of drugs in the general medical setting, including psychotropic drugs. Just how aggressive are some pharmaceutical manufacturers? 15

PIP Solution Target Population(s): Health plan benefit sponsors with more than 10 percent of their members having filled a PIP covered prescription in a recent 12 month period. An analysis of summary drug data across a number of health plans documented that between 80 and 90 percent of the plans met said criteria. Objectives for Solution: For mental health treatment occurring in the primary care setting: Identify and address gaps in clinical care Coordinate solution focused treatments Improve outcomes Increase number of patients who can successfully be tapered from medications (under prescribing physician s care) after achieving target symptom reduction 16

PIP Solution Implementation Plan and Metrics: Establish a secure two way data feed with the PBM Filter on drug data to identify potential candidates Coordinate a targeted member outreach Manage a concurrent authorization process with the PBM Provide telephonic evaluations, screenings and coaching Provide clinical outcomes to prescribing physician Coordinate with EAP for free psychotherapy and other resources Monitor side effects and drug adherence Provide education and feedback to participants and physicians 17

PIP Solution Results: A case study with St. Joseph s Hospital and Medical Center in Phoenix, AZ documented: Hundreds 200% 160% 120% 80% 40% 0% 96% 200% 96 percent higher medication compliance for PIP participants at 1 year 200 percent average increase in EAP engagement over 4 years 30% 60% 30 percent reduction in the PIP target drug spend within 15 months 60 percent of the PIP participants scored reduced symptoms based on multiple standardized screenings 29.4% 29.4 percent overall average reduction in total medical claims costs for the PIP participants in the year after enrolling in the PIP compared to prior year 18

PIP Solution Pricing: The PIP is priced on a per employee per month (pepm) basis that is determined for each group from an analysis of their summary drug data. Using a Concurrent Authorization (CA) process to maximize engagement, the PIP is provided with a financial guarantee reduced drug spend for the PIP target drugs (on a pepm basis) will exceed the cost of the PIP within 12 months or the difference will be refunded. It is important to note that the PIP is compliant with HIPAA, the ADA, and the mental health parity regulations, per established legal opinions. 19

Consider Why are so many Americans today, while they may not be disabled by mental illness, nevertheless plagued by chronic mental problems by recurrent depression, by bipolar symptoms, and by crippling anxiety? If we have treatments that effectively address these disorders, why has mental illness become an ever greater health problem in the United States? Anatomy of an Epidemic Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, Robert Whitaker, (2010) pg. 5 Think about the millions of Americans being prescribed psychotropic drugs by primary care physicians without any psychiatric diagnosis, monitoring, psychotherapy, or follow up to evaluate their conditions and changes in symptoms down the road. 20

Conclusion When one considers all of the available data associated with the prescribing of psychotropic drugs, the conclusion becomes clear. A grim picture is painted for the health and productivity of many Americans if interventions are not coordinated to improve treatments and health outcomes, leading to a reduction in the long term use of psychotropic drugs. The PIP Solution is a means to the improvement needed. The Problem is Clear The Solution is Proven The Cost is Free 21

For additional information, please contact us: Corporate Headquarters 10370 Richmond Ave. Suite 1100 Houston, Texas 77042 Phone: (713) 735 4019 Toll Free: (866) 951 9598 Email: info@cdhealthsol.com 22