Cmmnwealth f Kentucky Cabinet fr Health and Family Services Department fr Medicaid Services Drug Management Review Advisry Bard Meeting May 12, 2011 Meeting Minutes Vting Members in attendance: Kim Crley, Patricia Freeman (Telephne), Vice Chair, Kathy Hager, DNP, APRN, FNBC, CDE, Samuel Matheny, MD, Gerald Payne, B.S., BHS, PA-C, Michael Rager (Telephne), Clay Rhdes, PharmD, MBA, BCPS, Kathryn Schat, MD Nn-Vting Members in attendance: Steve Davis, MD, Laura Hiernymus Nn-members present frm Magellan Medicaid Administratin: Tina Hawkins, PharmD, Clinical Prgram Manager, Kasie Purvis, Prvider Services Manager Nn-members present frm Department fr Medicaid Services: Lee Barnard, Assistant Directr, Trista Chapman, Cntract Mnitr I. Welcme and Establishment f Qurum A qurum was present. Dr. Carmel Wallace has had t step dwn as Chair. The Bard will cntact Tina with nminatins fr Chair and a clsed-ballt vte will take place at the next meeting. II. Apprval f Nvember 4, 2010 Meeting Minutes Mtin t apprve the minutes as presented by Magellan Medicaid Administratin. Passed; 8 in favr, 0 against III. New Business (Slide Presentatin is embedded fr reference) [slides 3-47] May 2011 DMRAB Presentatin PUBLIC C A. Ppulatin Statistics (slides 4-6) On slide 4, it was nted that 16,000 mre members, 15,000 f which were children, utilized the pharmacy benefit during 1Q2011 when cmpared t 1Q2010. This des nt reflect new members; just utilizing members. B. Utilizatin Data (slides 8-36) Ttal Ppulatin (slides 8-11) On slide 10, it was nted that these data supprt the thery that cld and flu seasn was wrse this year cmpared t last. This culd als explain why 15,000 mre children utilized the benefit this quarter cmpared t last year. Children usually 1
present with acute illnesses rather than chrnic cnditins. The Bard discussed ways f encuraging prviders nt t use antibitics in patients with viral infectins. The Bard asked fr the percent f children wh gt flu vaccine, when and where the vaccinatin ccurred. They wuld like t see a match f children wh gt flu vaccine in crrelatin t the prescriptin fr an antibitic. The Bard asked if the Department fr Medicaid Services might want t team up with schl nurses t educate them abut the imprtance f flu vaccine and hw t get flu vaccine cvered. Adult Ppulatin (age 19 and abve) [slides 13-16] On slide 15, it was nted that 4 f the tp 10 are cntrlled substances with, street value. Child Ppulatin (ages 0 thrugh 18) [slides 18-21] On slide 19, the significant increase in payment fr antivirals was nted. It was als nted that Tamiflu was n manufacturer backrder last year, which may accunt fr sme f the difference in expenditures this year cmpared t last. The Bard discussed the ptential f lking at increases in pharmacy expenditures/claims t determine if cst savings were reflected in medical data. Fr example, maybe ur utilizatin f albuterl went up, but ur expenditures fr emergency department visits fr asthma related cmplicatins declined. Utilizatin by Disease State-Ttal Ppulatin (slides 23-24) The Bard was reminded that Behaviral Health encmpassed depressin as well as ADHD in additin t Atypical Antipsychtics. Chrnic pain is identified by utilizatin f a lng-acting narctic. If the lng-acting narctic is present, expenditures and claims fr shrt-acting narctics are included as well. This wuld nt capture patients n shrt-acting narctics lng-term. The Bard asked fr the number f patients n shrt-acting narctics fr >6 mnths. Utilizatin by Disease State-Adult Ppulatin (slides 26-27) The Bard was reminded that patients ver the age f 65 were usually Medicare eligible. Therefre, Medicaid was nly seeing claims fr drugs nt cvered by Medicare, such as benzdiazepines, barbiturates, OTC drugs and cld and cugh prducts. The Bard was als reminded that the lng-term-care pharmacy typical bills weekly rather than mnthly. Therefre, ne mnthly prescriptin will shw up in the data as fur claims. The Bard asked that benzdiazepine utilizatin be brken dwn by age. Utilizatin by Disease State-Child Ppulatin (slides 29-30) The Bard was very cncerned abut the number f children taking a lng-acting narctic. The Bard asked that the tp 10 prescribers f lng-acting narctics in children be identified as well as a gegraphical breakdwn. 2
The Bard expressed interest in develping prir authrizatin criteria fr lng-acting narctic use in children and lettering physicians wh have prescribed lng-acting narctics in children t determine their clinical ratinale. Tina will draft a letter fr the next meeting. Tp 10 Prescribers (slides 32-36) It was nted that the Bard culd send ut a letter t chrnic narctic users abut the negative lng term effects. Hwever, diverters are likely t be unaffected. In rder t ensure that patients get a urine drug screen, it wuld require that all lng-acting narctics require PA s that the call center culd receive a cpy f the urine drug screen. An ICD-9 fr pain is difficult t implement due t the verwhelming number f ICD-9s that culd be used. The Bard suggested that a PA nly be implemented after a few mnths f narctic use. The Bard als suggested that significant players, such as the Kentucky Medical and Licensure Bards, and DMS put tgether a wrking grup s that these issues can be addressed. It was als nted that nne f this narctic use is frm a Hspice patient as thse claims are nt paid fr by the pharmacy prgram. The Bard expressed cncern ver patients taking tw lngacting narctics r tw benzdiazepines cncurrently. A therapeutic duplicatin edit requiring a call center verride was suggested. The Bard suggested an activity that letters these tp 10 prescribers. The Bard als asked that we identify the prescribers specialty. It is pssible that pain management will nt cme up as a specialty, but we may be able t infer pain management by their specialty, such as anesthesilgy. The Bard wuld like t invite smene frm KASPER and the KY Bard f Medical Licensure t attend a DMRAB meeting t help the Bard determine a gd way t identify practitiners that shuld be targeted. The Bard was reminded that there is currently a therapeutic duplicatin edit n mre than ne benzdiazepine and lngacting narctic; hwever, that edit is able t be verridden by the pharmacy. The Bard asked if we culd allw ne verride per 60 days t allw fr a change in drug due t allergy r therapeutic failure. C. Prspective Drug Utilizatin Review (PrDUR) [slides 38-41] D. Severity Level 1 Drug-t-Drug Interactins The Bard was reminded that they had requested t take a lk at sme f the PrDUR edits t ensure that we are nt messaging pharmacies unnecessarily. These drug-t-drug interactins are cnsidered t be severity level 1, meaning these drugs are cntraindicated t be given tgether. 3
It was nted that these interactins are assigned by ur drug file, First DataBank. They use current literature t assign the interactins and severity level, which is updated peridically. Drugs that have been remved frm the market are als included here t prevent the need t re-cde the interactin if anther similar drug that wuld be expected t have the same interactin enters the market as well as t prevent unnecessary system changes. It was nted that the interactin between linezlid and SSRIs was theretical and shuld be remved. The Bard wuld like fr Tina t remve any drug-t-drug interactins invlving drugs that are n lnger available. They wuld like t take mre time t review the interactins and discuss at the next meeting. E. Review f Retrspective Drug Utilizatin Review (RetrDUR) Activities [slides 43-45] On slide 43, the Bard was reminded that they had riginally asked that the threshld be >3 cntrlled substances. Due t excessive amunts f patients that were n 4 r mre, the query was changed t be >4 cntrlled substances. The Bard asked that we investigate the pssibility f making the envelpe distinct t help mtivate the prvider t pen the letter and respnd. Pssibly put a statement n the frnt which says, Respnse Required. F. Future DUR Activities (slides 46-47) On slide 46, it was nted that the number f patients taking enxaparin fr mre than 10 days seemed reasnable. It is cmmn fr patients wh are pregnant t take the drug thrughut pregnancy and there are certain indicatins which require 14 days f therapy. On slide 47, it was nted that the number f patients taking a PPI alng with clpidgrel was prbably apprpriate as well. G. The fllwing tpics were chsen: Patients with a diagnsis f diabetes withut an ACEI, ARB r Direct Renin Inhibitr Pregnancy Categry D Drugs given t a patient wh is pregnant. Patients with a diagnsis f Cngestive Heart Failure withut an ACEI, ARB r Beta Blcker H. The fllwing data were requested fr the next meeting: The percent f children wh gt flu vaccine, when and where the vaccinatin ccurred A match f children wh gt flu vaccine in crrelatin t the prescriptin fr an antibitic Number f patients n shrt-acting narctics fr >6 mnths Benzdiazepine utilizatin brken dwn by age Tp 10 prescribers f lng-acting narctics in children identified Gegraphical breakdwn f prescribers f lng-acting narctics in children IV. Meeting Adjurned A. Future Meetings 4
August 11, 2011 Nvember 10, 2011 B. Cllectin f Travel Vuchers 5