Arkansas Medicaid Antipsychotic

Utilization in ChildrenArkansas Children’s Behavioral Health Care Commission

AR DHS Division of Medical Services Pharmacy ProgramLaurence H. Miller, M.D., Senior Psychiatrist

Pamela Ford, P.D., MBASuzette Bridges, P.D., Pharmacy Director

Stacy Simpson, M.D., Child PsychiatristJanuary 16, 2014

EDITS ON PSYCHOTROPIC MEDICATIONS

Oct 1, 2003: Implemented manual review Prior Authorization (PA)

process for C-II stimulants requested for children < 5 yrs of age;

Nov 15, 2006: Implemented quantity and dose-optimization edits in

all C-II stimulants; most limited to 2x the maximum FDA recommended dose.

Implemented Therapeutic Duplication (TD) edits that limited C-II stimulants to one short-acting agent and one long-acting agent with overlapping days’ supply for all Medicaid beneficiaries.

Prior Authorization (PA) Edits for C-II Stimulants

History of Education Beginning in the latter part of 2003, DMS and DBHS

worked together on a behavioral health (BH) educational project with prescribing providers;

Letters were mailed regarding poly-pharmacy of BH meds, TD of BH medications, multiple prescribers, etc.;

Project terminated after 2 years with little appreciable changes in prescribing habits;

The “multiple prescriber” edit facilitated increased communication among providers raising awareness of “doctor shopping”;

Reviewing Antipsychotic Utilization in Children

Beginning in January 2008…. DMS began working with 2 psychiatrists at

the Division of Behavioral Health Services (DBHS) to develop edits which focused on the utilization of antipsychotic agents in AR Medicaid children. These included: ◦High Doses;◦Multiple Agents Used;◦Use In Children <5 Yrs of Age;

Antipsychotic PA Edits in Children

July 2009 Implemented Prior Authorization (PA)

criteria: Manual Review PA required for all children <5 yoa; Point of Sale (POS) TD edits –these edits allowed one oral

antipsychotic agent; a second agent required Manual Review PA; Dose edits implemented for all oral 2nd generation antipsychotic

agents* for 3 age groups: <5 yoa; 5‐12 yoa, and 13‐17 yoa;*(aripiprazole (Abilify), olanzapine (Zyprexa), risperidone (Risperdal), ziprasidone (Geodon), quentiapine (Seroquel). As newer antipsychotic agents were introduced to market they were placed under manual review PA.)

4 DBHS/ASH Child Psychiatrists volunteered their time & shared the responsibility for reviewing PA requests.

Antipsychotic PA Edits in Children

Effects of July 2009 Edits:◦Decreased utilization in the < 5 age group

by 70%;

◦Decreased utilization in the 5-12 and 13-17 age groups by 10%;

◦The number of children receiving more than 1 antipsychotic drug decreased, although the overall number of children receiving antipsychotic medication did not decrease significantly.

Antipsychotic Utilization in Children

November 2011 ALL claims for “NEW STARTS” rejected at

POS –a PA REQUIRED a Signed INFORMED CONSENT and Metabolic Labs for fasting lipids & glucose;

Increased age to < 6 yoa for PA through Manual Review by a DBHS/ASH child psychiatrists;

Antipsychotic Edits in Children Added

June 2012 ALL Children < 18 yoa on antipsychotic

agent (“established” patients) now required to have metabolic lab tests for fasting lipids and glucose required every 6 months;

A change in chemical entity (from one medication to another) rejected at POS and required a new signed informed consent for the PA approval;

Antipsychotic Edits in Children Added

July 9, 2013 Implemented additional edits approved at the April 2013 DUR Board meeting:

Added manual review PA to all long-acting or depot injectable antipsychotic agents for children < 18 yrs of age;

Added therapeutic duplication edits for long-acting or depot injectable antipsychotic agents to edit against oral antipsychotic agents;

Antipsychotic Edits in Children Added

Oct. 15, 2013 Added age-related dose edits and dose-

optimization quantity limit for oral 1st generation antipsychotic agent;

Added age-related dose edits and dose-optimization quantity limit for iloperidone (Fanapt), lurasidone (Latuda), and asenapine (Saphris);

Antipsychotic Edits Added for Children < 18 yrs.

Lowered the previously approved dose edits for each age group for oral 2nd generation antipsychotic agents;

Divided the middle age group of 6-12 yrs. to 6-9 yrs. and 10-12 yrs.;

Manual review all requests for children for doses greater than 1 per day of naltrexone (off label use);

Manual review any requests for any Alzheimer disease agents (off label use);

Antipsychotic Edits Added for Children < 18 yrs.

January 2013 Medicaid Pharmacy Program hired 1 ½ FTE psychiatrists:

Now questioning the diagnoses on manual review requests;

Currently reviewing antipsychotic utilization patterns in children;

Reviewing Medicaid drug profiles of children who are receiving >5 mental health drugs & consulting with the prescribers regarding the therapy;

Reviewing PA exception from prescribers who request to waive the required metabolic labs for the child;

Additional Changes for the Pharmacy Program

January 2013, Medicaid Pharmacy Program hired 1½ FTE psychiatrists continued:

Regularly consulting with the Division of Children and Family Services (DCFS) staff regarding use of psychotropic medications in foster children;

Collaborating with the System of Care (SOC) clinical staff requesting that they work with providers and families of children with outlier medication profiles to determine if their treatment plans are adequate to address their psychosocial issues (which could also decrease medication utilization);

Consulting with the Value Options Care Coordination Team reviewing complex cases with multiple hospitalizations and excessive use of medications;

Additional Changes for the Pharmacy Program cont’d

Oct 2013 AR developed an educational

intervention letter with the RDUR contractor to mail to prescribing providers regarding children who are receiving an antipsychotic agent and have a trauma diagnosis in medical history with no other MH diagnosis to support its use.

Educational Interventions for the Pharmacy Program

Dec 2013 Developed an educational intervention letter

with RDUR contractor to notify the prescribing provider that although the patient is receiving a C-II stimulant medication there is no supporting diagnosis of ADHD/ADD or narcolepsy in medical history. The informational letter explains that off label uses, diversion, and abuse are concerns with C-II stimulant medications and that these agents have serious adverse effects and should only be used for FDA approved indications.

Educational Interventions for the Pharmacy Program

Adding dose ranges (min. and max) for children receiving antidepressant agents;

Lowering the daily dose allowed for C-II stimulants;

Future DUR Board Topics for Children

The Outcomes of the Antipsychotic Edits

% Medicaid Children are on Antipsychotic Agent

% Foster Care Children are on Antipsychotic Agent out of Total Foster Care Population

% NON-Foster Care Children are on Antipsychotic Agent out of Total NON-Foster Care Population

Jul-1

3

Aug-1

3

Sep-

13

Oct-1

3

Nov-1

30.00%1.00%2.00%3.00%4.00%5.00%6.00%7.00%8.00%9.00%

10.00%

% of FOSTER Children <6 yoa on antipsychotic drug

% of FOSTER Children 6-12 yoa on an-tipsychotic drug

% of FOSTER children 13-17 on antipsychotic drug

Jul-1

3

Aug-1

3

Sep-

13

Oct-1

3

Nov-1

30.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%

1.60%% of NON-FOS-TER Medicaid Children <6 yoa on antipsychotic drug

% of NON-FOS-TER Medicaid Children 6-12 yoa on an-tipsychotic drug

% of NON-FOS-TER Medicaid Children 13-17 yoa on an-tipsychotic drug

Outcomes from Antipsychotic Edits

May-11

Jun-11Jul-1

1

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11Jan

-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12Jul-1

2

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12Jan

-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13Jul-1

3

Aug-13

Sep-13

Oct-13

Nov-13

0

50

100

150

200

250

NON-FOSTER Children < 6 yrs of age Changes in Antipsychotic Utilization

# children < 6 yoa on antipsychotic

# children < 6 yoa on C-II Stim.+ antipsychotic

# children < 6 yoa on both C-II Stim + AP with behavioral therapy his-tory in prior 6 months

# children < 6 yoa on both Strat-tera + Antipsychotic

# children < 6 yoa on both Strat-tera + Antipsychotic with behav-ioral therapy history in prior 6 months

Informed con-sent & lab Memo mailed 8/31/11

New Starts In-formed Con-sent & Labs implemented Nov 2011

Incorpo-rated estab-lished pts for Meta-bolic Labs q6mo June 2012

Existing TD criteria & dose ed-its re-mained in effect

Provider letter mailed 1/23/13 re-garding use of C-II stim. + an-tipsychotic combination

Outcomes from Antipsychotic Edits

May-11Jul-11

Sep-11Nov-11

Jan-12Mar-1

2May-12

Jul-12Sep-12

Nov-12Jan-13

Mar-13

May-13Jul-13

Sep-13Nov-13

0

500

1,000

1,500

2,000

2,500

3,000

3,500

NON-FOSTER Children 6-12 yrs Changes in Antipsychotic Utilization

# children 6-12 yoa on An-tipsychotic

# children 6-12 yoa on C-II Stim.+ antipsychotic

# children 6-12 yoa on both C-II Stim + Antipsychotic with behavioral therapy history in prior 6 months

# children 6-12 yoa on both Strattera + Antipsychotic

# children 6-12 yoa on both Strattera + Antipsychotic with behavioral therapy history in prior 6 months

Axis Title

Informed consent & lab Memo mailed 8/31/11

New Starts Re-quire Consent Forms & Labs implemented Nov 2011

Metabolic Labs required for all children every 6 months imple-mented June 2012

Existing TD criteria & dose edits remained in effect

Provider letter mailed 1/23/13 regarding use of C-II stim. + an-tipsychotic combo

Outcomes from Antipsychotic Edits

May-11

Jun-11Jul-1

1

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11Jan

-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12Jul-1

2

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12Jan

-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13Jul-1

3

Aug-13

Sep-13

Oct-13

Nov-13

0

500

1,000

1,500

2,000

2,500

NON-FOSTER Children 13-17 yrs Changes in Antipsychotic Utilization

# children 13-17 yoa on An-tipsychotic

# children 13-17 yoa on C-II Stim.+ antipsychotic

# children 13-17 yoa on both C-II Stim + Antipsychotic with behav-ioral therapy history in prior 6 months

# children 13-17 yoa on both Strattera + Antipsychotic

# children 13-17 yoa on both Strattera + Antipsychotic with behavioral therapy history in prior 6 months

Metabolic Labs required for all children every 6 months imple-mented June 2012

New Starts Require Con-sent Forms & Labs imple-mented Nov 2011

Informed con-sent & lab Memo mailed 8/31/11

Existing TD criteria & dose edits remained in effect

Provider letter mailed 1/23/13 re-garding use of C-II stim. + antipsy-chotic combo

Outcomes from Antipsychotic Edits

May-11

Jun-11Jul-1

1

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11Jan

-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12Jul-1

2

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12Jan

-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13Jul-1

3

Aug-13

Sep-13

Oct-13

Nov-13

0

5

10

15

20

25

FOSTER CARE Children < 6 yrs Changes in Antipsychotic Utilization

# FOSTER children <6 YOA on Antipsychotic

# FOSTER children <6 YOA on C-II Stim.+ antipsychotic

# FOSTER children <6 YOA on both C-II Stim + Antipsy-chotic with behavioral ther-apy history in prior 6 months

# FOSTER children <6 YOA on both Strattera + Antipsy-chotic

# FOSTER children <6 YOA on both Strattera + Antipsy-chotic with behavioral ther-apy history in prior 6 months

Existing TD cri-teria & dose ed-its remained in effect

Informed Con-sent and Lab Memo mailed 8/31/11

Nov 2011 New Starts Require Consent Forms & Labs

June 2012 Es-tablished pts included in Metabolic Labs required for all children every 6 months

Provider letter mailed 1/23/13 re-garding use of C-II stim + an-tipsychotic combo

Outcomes from Antipsychotic Edits

0

50

100

150

200

250

300

FOSTER CARE Children 6 TO 12 yrs Changes in Antipsychotic Utiliza-tion

# FOSTER children 6-12 YOA on Antipsychotic

# FOSTER children 6-12 YOA on C-II Stim.+ antipsychotic

# FOSTER children 6-12 YOA on both C-II Stim + Antipsy-chotic with behavioral therapy history in prior 6 months

# FOSTER children 6-12 YOA on both Strattera + Antipsy-chotic

# FOSTER children 6-12 YOA on both Strattera + Antipsy-chotic with behavioral therapy history in prior 6 months

Existing TD criteria & dose edits remained in effect

Informed Consent and Lab Memo mailed 8/31/11

Nov 2011 New Starts Re-quire Consent Forms & Labs

Metabolic Labs re-quired for all chil-dren every 6 months

Provider letter mailed 1/23/13 RE use of C-II stim + antipsychotic combo

Outcomes from Antipsychotic Edits

May-11

Jun-11Jul-1

1

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11Jan

-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12Jul-1

2

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12Jan

-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13Jul-1

3

Aug-13

Sep-13

Oct-13

Nov-13

0

50

100

150

200

250

300

FOSTER CARE Children 13 TO 17 yrs Changes in Antipsychotic Utilization

# FOSTER children 13-17 YOA on Antipsychotic

# FOSTER children 13-17 YOA on C-II Stim.+ antipsychotic

# FOSTER children 13-17 YOA on both C-II Stim + An-tipsychotic with behavioral therapy history in prior 6 months

# FOSTER children 13-17 YOA on both Strattera + Antipsy-chotic

# FOSTER children 13-17 YOA on both Strattera + Antipsy-chotic with behavioral therapy history in prior 6 months

Existing TD criteria & dose edits remained in effect

Informed Consent and Lab Memo mailed 8/31/11

Nov 2011 New Starts Require Con-sent Forms & Labs

June 2012Metabolic Labs required for all children every 6 months

Provider letter mailed 1/23/13 RE use of C-II stim + antipsychotic combo

COMPARING ANTIPSYCHOTIC UTILIZATION FROM 4Q8 (NO EDITS IN EFFECT) TO MOST CURRENT 3 MONTHS (SEPT., OCT., NOV. OF 2013):

IMPACT IN UTILIZATION AS A % CHANGE FOR EACH GROUP

FOSTER CARE CHILDREN <6 YRS

FOSTER CARE CHILDREN 6-12 YRS

FOSTER CARE CHILDREN 13-17 YRS

-86.02% -38.80% -17.54%

NON-FOSTER CARE CHILDREN <6 YRS

NON-FOSTER CARE CHILDREN 6-12 YRS

NON-FOSTER CARE CHILDREN 13-17 YRS

-92.69% -49.35% -31.23%

SUMMARY OF ACCOMPLISHMENTS

SIGNIFICANT DECREASES IN INAPPROPRIATE UTILIZATION OF ANTIPSYCHOTIC AGENTS IN ALL AGE GROUPS OF CHILDREN;

NOW BEGINNING TO QUESTION DIAGNOSIS TO TREATMENT DURING THE MANUAL REVIEW PROCESS & CONSULT WITH PRESCRIBER;

IMPROVING OVERALL CARE BY REQUIRING LAB WORK AND SIGNED INFORMED CONSENTS;

ACCOMPLISHMENTS

INCREASED COLLABORATIONS WITH OTHER ORGANIZATIONS, SUCH AS DCFS, SOC, VALUE OPTIONS FOR IMPROVED CARE;

RAISING AWARENESS ABOUT ADDRESSING PSYCHOSOCIAL ISSUES RATHER THAN JUST USING MEDICATIONS.

ACCOMPLISHMENTS