Articles, News Releases, and Poster Presentations

Missouri Sees $7.7 Million in Mental Health Services Savings

Novel Program Gives Patients Better Care While Cutting Inefficiencies

For media inquiries, please contact:
Beth Champlin, Standing Partnership
(314) 469-3500 or bchamplin@standingpr.com

Jefferson City, Mo., (Dec. 9, 2004) - An innovative program to increase the quality of care that Missouri residents with severe mental illnesses receive, while encouraging more efficient use of Medicaid dollars appears to have achieved both its goals, a recent analysis shows.

The Missouri Mental Health Medicaid Pharmacy Partnership Program (MHMPP), the first program of its kind in the United States, evaluates Medicaid mental health prescribing practices. The program seeks to improve care for Missouri residents by educating doctors about evidence-based best practices for mental health medications and reducing inefficient and ineffective prescribing patterns.

"Not only did the MHMPP program positively affect the quality of care received by Missourians suffering from severe mental illness, it also allowed Missouri to save $7.7 million in costs the Medicaid program would have incurred in state fiscal year 2004 had the inefficient prescribing patterns not been identified", said Joseph Parks, M.D., medical director of the Missouri Department of Mental Health.

"We were pleased to see that most Missouri doctors are following the recommended guidelines when prescribing medications. We have identified the small number of doctors who aren't and are reaching them with educational materials to help change their prescribing habits. These changes have resulted in better patient care and savings for our Medicaid program", said Parks.

Some of the inefficient prescribing patterns the program identifies include duplicative prescribing of medication by different doctors for the same patient; prescribing multiple medications from the same therapeutic class; children on three or more psychotropic medications; and premature, rapid switching from one medication to another.

After reviewing, identifying, and analyzing problematic prescribing patterns, the program provides doctors deviating from best practices with information to help them make patient-care decisions based on the latest medical evidence.

The MHMPP program is entirely voluntary for Missouri doctors. All decisions regarding treatment and medications are made privately between the physician and the patient and are completely individualized.

An analysis from the program's first year shows the following:

The MHMPP was developed by the Missouri Department of Mental Health and the Missouri Department of Social Services' Division of Medical Services, in collaboration with Comprehensive NeuroScience, Inc. Eli Lilly and Company, an Indianapolis-based pharmaceutical company, has been providing financial support for this program in an effort to promote excellence in patient health care.

"The program is a model of cooperation among state agencies. It represents a collaboration of the clinical resources of our staffs, the industry, and our providers. Most importantly, it assures our most vulnerable citizens the greatest access to best medical practices and current therapies, while being sensitive to our limited resources", said Christine Rackers, director of the Missouri Department of Social Services' Division of Medical Services.

The program also has proven to be popular outside of Missouri. Fifteen other states have signed contracts to develop similar programs, buoyed by the increasing awareness that mental health is integral to physical health. This project demonstrates two traits other states are eager to copy:

  1. That management of mental health drugs should be based on nationally recognized standards and guidelines, as well as individual patient needs, to ensure the highest quality care; and
  2. That Medicaid dollars for mental health drugs can be wisely managed by focusing directly on the quality of prescribing practices.

"We fully support cost-effective programs like this that focus on improving patient care while encouraging more efficient use of taxpayer dollars", said Jack Bailey, Lilly vice president, Business to Business. "We believe a significant opportunity exists within the Medicaid system to reduce costs by improving the quality of care and patient outcomes, and we applaud Missouri's leadership and innovation with this project."

For more information on this project, visit the DMH Web site and DMS.

back to top


Missouri achieves success with Medicaid pharmacy initiative

(reprint from Dec. 20, 2004 issue of Mental Health Weekly)

back to top


For media inquiries, please contact:
Janice Chavers, Eli Lilly and Company
(317) 651-6253 or chaversjm@lilly.com

Study Shows How Improving Quality of Psychotropic Prescribing Practices Reduces Hospital Utilization

Innovative program gives patients better care while cutting inefficiencies

Jefferson City, Mo. (Nov. 16, 2005) - An innovative program appears to play a role in the overall reduction in hospital utilization and cost of care for Missouri Medicaid recipients with severe mental illness.

The Missouri Mental Health Medicaid Pharmacy Partnership Program (MHMPP), the first program of its kind in the United States, evaluates Medicaid mental health prescribing practices. The program seeks to improve care for Missouri residents by educating doctors about evidence-based best practices for mental health medications and reducing inefficient and ineffective prescribing patterns.

"This is a model on how states can increase the quality of care that Medicaid residents with severe mental illnesses receive while encouraging more efficient use of taxpayer dollars," said Joseph Parks, M.D., medical director of the Department of Mental Health. "We are excited that we can start sharing data about the success of the program at national medical meetings."

The poster, "Improving Quality of Psychotropic Prescribing Reduces Hospital Utilization" was presented at the recent American Psychiatric Association Institute on Psychiatric Services meeting and the Disease Management Association of America meeting, where it received the Gold Award for first place. Awards are presented to recognize excellence in program design and implementation and leadership in outcomes research and the positive impact on individual health and the disease management industry.

The MHMPP was developed by the Missouri Department of Mental Health and Missouri Department of Social Services, Division of Medical Services, in collaboration with Comprehensive NeuroScience, Inc. (CNS) Eli Lilly and Company, an Indianapolis-based pharmaceutical company, has been providing the financial support for this program in an effort to promote excellence in patient health care.

The pharmacy partnership program began with the evaluation of Medicaid prescribing records. With this information, the state identified a small number of doctors who weren't following recommended guidelines for prescribing and reached out to them with educational materials to help change their prescribing habits. This information is designed to help them make patient care decisions based on the latest medical evidence.

"These changes in prescribing have resulted in better patient care and savings for our Medicaid program. We begin to see change within 90 days of the first mailing," Parks said. The study presented at the psychiatric services meeting highlights the success of the program.

Dr. Richard Surles, CNS executive vice president, explained that 1,911 Medicaid recipients whose physicians received notification for at least one of the program's quality indicators during two consecutive mailings were used for the analysis presented at the medical meeting. Individuals similar to those patients were selected for the comparison group. They compared a number of factors six months pre-intervention and six months post-intervention.

The researchers found:

"We were very pleased with the results. Not only do they show that there was not a disruption in patient care, but the program appears to play a role in the overall reduction in hospital utilization and cost of care for patients," Parks said. "Thus, this program helps control costs for the states, while it ensures that the patients have access to the appropriate medications and treatments they need."

One factor in the cost reduction was the identification of inefficient prescribing patterns, including:

Earlier data from the program also is indicative of its success. An analysis from the program's first year shows: 98 percent reduction of patients who are prescribed the same mental health medications from multiple doctors; 64 percent reduction of patients who are on two or more mental health medications of the same type; 43 percent reduction of children on three or more psychotropic medications; and 40 percent reduction of patients receiving an unusually high dosage of medication.

"Not only did the MHMPP program positively affect the quality of care received by Missourians suffering from severe mental illness, it also allowed Missouri to save $7.7 million in costs the Medicaid program would have incurred in state fiscal year 2004 had the inefficient prescribing patterns not been identified," Parks said.

The MHMPP program is entirely voluntary for Missouri doctors. All decisions regarding treatment and medications are made privately between the physician and the patient and are completely individualized.

The program also has proven to be popular outside of Missouri. Twenty-five other states have signed contracts to develop similar programs.

For more information on this project, visit the DMH Web site and DMS.

back to top


Missouri pharmacy program decreases hospitalization for HealthNet SMI patients

Mental Health Weekly December 12, 2005

A recent study of the Missouri Department of Mental Health HealthNet pharmacy initiative found that improving the quality of psychotropic prescribing practices has led to an overall reduction in hospital utilization and the cost of care for Missouri HealthNet recipients with severe mental illness (SMI), officials announced last month.

Researchers studied the states Behavioral Pharmacy Management (BPM) program, referred to as the Missouri Mental Health HealthNet Pharmacy Partnership Program (MHMPP). The MHMPP is the first program of its kind in this country, said officials. Now in its third year, the program evaluates mental health prescribing practices. Its aim is to improve care for Missouri residents by educating doctors about evidence based practices for mental health medications and reducing inefficient and ineffective prescribing patterns.

Missouri’s pharmacy initiative has saved the state $ 7.7 million in costs the HealthNet program would have incurred in fiscal 2004 had the inefficient prescribing patterns not been identified, according to officials (see MHW, Dec. 20, 2004).

The BPM is an alternative to preferred drug lists, prior authorizations for psychiatric medications, fail first approaches or intensive case management. The educational intervention functions as a quality improvement tool that also produces cost savings by aligning outlier with best practices. To date, approximately 25 states have embarked on similar BPM programs. Researchers presented a poster of the study results, “Improving Quality of Psychotropic Prescribing Reduces Hospital Utilization,” during the American Psychiatric Association (APA) Institute on Psychiatric Services meeting and the Disease Management Association of America meeting in October where it received a Gold Award. Awards are presented to recognize excellence in program design and implementation and leadership in outcomes research and the positive impact on individual health and the disease.

The study involved 1,911 HealthNet recipients whose physicians received notification for at least one of the program’s quality indicators during two consecutive mailings that were used for the analysis. Individuals similar to those patients were selected for the comparison group. Researchers compared a number of factors six months preintervention and six months postintervention and found:

The BPM program does not cause a disruption in patient care, according to researchers. Compared to more complex and costly changes, the relatively low cost BPM intervention helps the state to identify the HealthNet recipients who are of greatest concern from a financial perspective, they said. The medical director of the Missouri Department of Mental Health told MHW he was pleased and surprised by the findings. “It was more positive than we expected to find,” said Joseph Parks, M.D., citing the decrease in hospital admission and the total number of inpatient days. The findings revealed a 20 percent decrease in total health care costs, although they had hypothesized that the total percentage of health care costs would be more like 10 to 15 percent, said Parks.

Analyzing prescription drug claims

According to researchers, prescription drug claims are analyzed monthly from the state’s HealthNet program to identify questionable prescribing patterns such as pre-scribing three or more antipsychotics; multiple prescribers for antipsychotics; and prescribing an unusually high or low dose of antipsychotics.

All physicians who are identified as having potential deviations from best practice guidelines as outlined in the quality indicators above received a mailed intervention that includes:

According to researchers, one factor in the cost reduction was the identification of inefficient prescribing patterns, including:

Pharmacy partnership

The MHMPP was developed by the Missouri Department of Mental Health and Missouri Department of Social Services, Division of Medical Services, in collaboration with Comprehensive NeuroScience, Inc. (CNS). Eli Lilly and Company has been providing the financial support for this program in an effort to promote excellence in patient health care, said officials. The pharmacy partnership program began with the evaluation of HealthNet prescribing records. This information helped the state identify a small number of doctors who weren't’t following recommended guidelines for prescribing and reached out to them with educational materials to help change their prescribing habits. This information is designed to help them make patient care decisions based on the latest medical evidence. “This is a model on how states can increase the quality of care that HealthNet residents with severe mental illnesses receive while encouraging more efficient use of taxpayer dollars,” said Parks. “This program helps control costs for the states while it ensures that the patients have access to the appropriate medications and treatment they need.” “Our project is aimed at inappropriate overutilization,” said Parks. Medication non-adherence accounts for increases in hospitalization, he noted. “Patients get medications from more than one doctor and often don’t tell us,” said Parks. “Seventy percent of all schizophrenia-related hospitalizations are the result of patients having stopped taking their medication.” The MHMPP program is entirely voluntary for Missouri doctors. All decisions regarding treatment and medications are made privately between the physician and the patient and are completely individualized. “This approach is respectful of physician and patients and the autonomy to make that final decision,” said Parks. “This isn’t a fail-first approach. Nobody is forced to do anything. We provide more information for the doctor to make a decision.” Parks added, “It does not take the responsibility out of the hands of physicians and their patients.”Other pharmacy management programs tend to get unintended negative consequences, said Parks. “We try to get the most current information to physicians. There is so much information out there. Physicians do not have enough time to wade through that information.”A total of 26 states have embarked on the Behavioral Pharmacy Management program, John Byrd, director of outcomes research at Comprehensive NeuroScience, told MHW. “We’re looking at four other states,” Byrd. “We’re trying to do a multi-state validation of what we found in Missouri.” Plans also include submission of the study’s findings to a peer review journal within the next couple of months, which will include preliminary findings from another state where the program has been active for two years, noted Byrd. Officials also expect to present findings from at least five other states within the next year, he added.

back to top


Missouri Medical Risk Management program a focus of national effort to foster best practices in caring for chronically ill HealthNet patients

Possible outcome of project: showing states options to better manage their HealthNet budgets while giving patients the care they need

Comprehensive NeuroScience, Inc. (CNS), has been selected as one of 10 organizations to join a national collaborative to improve care for HealthNet consumers with numerous health issues.

The Center for Health Care Strategies selected 10 organizations, which are being asked to develop and test models of care delivery for HealthNet consumers with multiple chronic conditions. The HealthNet Value Program: Health Supports for Consumers with Chronic Conditions is funded by Kaiser Permanente Community Benefit with additional funding from The Robert Wood Johnson Foundation. Each organization will receive a grant of $50,000 for its participation in the collaborative.

When the two-year project is complete, the Center for Health Care Strategies will issue a toolkit, providing an opportunity for states, health plans, consumer groups and providers across the country to apply the tools to improve the quality of care for other HealthNet beneficiaries with chronic needs.

CNS’ work will focus on the Medical Risk Management Program (MRM) it operates for the Missouri Department of Mental Health and the Division of Medical Services. The program is funded by Eli Lilly and Company.

“We are thrilled to be a part of this prestigious project. We believe that MRM is a perfect fit for the program. This is an excellent opportunity to demonstrate that coordinating mental health with physical health improves overall health outcomes,” said Dr. Richard Surles, senior vice president of CNS.

Surles explained that Missouri’s MRM program focuses on HealthNet recipients who are diagnosed with schizophrenia, a severe mental illness that affects up to 3 percent of the HealthNet population. People diagnosed with schizophrenia are twice as likely to have major medical illnesses such as diabetes, hypertension, health failure, asthma, digestive and lung disorders (Marder SR, et al. Physical health monitoring of patients. Am J Psychiatry. 2004. Aug; 16 (8);1334-49.)

The disease can lead to disability and long-term dependence on government payers, especially HealthNet.

In Missouri alone, over 19,000 HealthNet recipients had a diagnosis of schizophrenia with the top 2,000 of them having a combined cost of about $100 million for pharmacy, medical and psychiatric services. Pharmacy expenditures comprised only about 20 percent of the overall costs while the majority were related to numerous urgent care, emergency room and inpatient visits, according to CNS.

“We see the MRM program as a way for states to use disease management principles to get appropriate care for these patients while controlling the costs associated with their treatment,” Surles said.

The researchers created an algorithm to identify patients with a diagnosis of schizophrenia who are at higher risk of adverse health outcomes and higher service (medical, pharmacy and behavioral) costs. Three thousand individuals were identified and, in phases, are being enrolled in disease management programs and services to better manage their health care.

For example, the patient’s health care providers can work together for:

“By addressing the patient’s health care needs, we hope to be able to show lower health care costs per patient when compared to costs of similar patients not involved in the MRM program,” Surles said.

The researchers already are having opportunities to share details about this innovative project. The algorithm was the topic of a recent poster presentation at American Psychiatric Association’s Institute on Psychiatric Services Meeting in San Diego.

“We were very pleased to see that the predictive algorithm identified the HealthNet recipients who have high medical services and pharmacy expenditures. The model also identified patients who have both severe medical and psychiatric illnesses,” said Joseph Parks, M.D., medical director of the Department of Mental Health. “The next steps are to implement programs designed for this population and measure key health outcomes. We are very excited about the possible outcomes that could point to ways for states to better manage their health care budgets while continuing to provide high quality care for these patients.”

For more information: Anne M. McCabe~ Comprehensive NeuroScience, Inc. ~ 518-580-9527

back to top


Missouri's Experiment to Increase Quality - and Decrease Costs

Behavioral Healthcare ~February 2006 One state's program gives physicians a “heads up” about their prescribing practices by JOHN E. BYRD, RPH, MBA, JOSEPH PARKS, MD, GEORGE OESTREICH, PharmD, MPA, and RICHARD SURLES, PhD

Prescription drugs account for only 11% of national healthcare spending, but expenditures for drugs have been growing at an annual rate of 15%, which is higher than the increases seen in either physician and clinical services or hospital care.1 This increase can be attributed to growth in prescription drug use, newer and more expensive drug therapies that replace older and less expensive ones, and price increases by pharmaceutical manufacturers. Of these contributing factors, the increase in overall utilization has had the greatest impact on spending and was responsible for 42% of the overall increase in prescription drug spending between 1997 and 2002.1

Prescription medications to treat psychiatric conditions are among the most costly drugs for HealthNet programs. The cost of antidepressants and antipsychotics has been reported to be nearly 20% of HealthNet prescription drug expenses, with all psychiatric medications accounting for one-third of those expenses.2,3

States React

These prescription drugs’ costs and the overall HealthNet prescription drug benefit have received much legislative attention during the past few years, primarily because of state budget shortfalls.4 States have implemented a variety of cost-containment strategies, including restricted formularies with preferred drug lists, physician prior authorizations, prescription limits, generic substitutions, and increases in patient copayments.4 In addition to programs aimed mainly at cost containment, interventions (e.g., case management for complex patients) have been adopted to improve quality of care and moderate long-term expenses.

States may modify the design of their HealthNet prescription drug benefit, and they may choose to adopt one or several of these approaches to combat growing costs. Forty-six states adopted at least one new cost-containment strategy during 2003 in an effort to control prescription drug spending within their HealthNet program.2 Adoption of these policies is not always done empirically, and exemptions sometimes are made for certain drugs or drug groups, such as psychiatric medications. Studies have indicated that traditional pharmacy utilization-management interventions (such as step algorithms, prior authorizations, prescription limits, and restricted formularies) undertaken solely with a cost-reduction goal in behavioral healthcare can have extremely negative effects on people with serious mental illnesses.5–7 A recent review of pharmacy-utilization management initiatives for psychiatric medications concluded that a greater focus on quality may be effective at containing costs while avoiding unintended negative consequences.8

Missouri's Approach

As an alternative to preferred drug lists, fail-first approaches, case management, or prior authorizations for psychiatric medications, the Behavioral Pharmacy Management (BPM) intervention (a clinical analytic product created by Comprehensive NeuroScience, Inc.) was designed as a quality-improvement tool that also produces cost savings by aligning outlier physician prescribing practices with best practices.3 The intervention is predicated on profiling and modifying physicians’ prescribing practices through an educational intervention in an effort to bring prescribing into alignment with best-practice guidelines. The assumption is that the intervention results in decreased hospitalization rates and use of hospital services—a recognized outcome for interventions—and this subsequently will decrease the patient's overall cost of care.9,10

The BPM is the result of the Mental Health HealthNet Pharmacy Partnership program implemented in Missouri in the first quarter of 2003.3 Each month, the prescription drug claims for the HealthNet program are analyzed by comparing them to multiple quality indicators indicative of questionable prescribing patterns, such as:

Physicians identified as having potential deviations from best-practice guidelines (as outlined in the quality indicators) are mailed an intervention, which includes a “quality-consideration” letter that outlines the potential deviation, a 90-day pharmacy claims history of patients in their practices to whom the selected indicator applies, and best-practice guidelines and empiric references related to the clinical issue. This mailed intervention is the primary mechanism within the program that encourages physician behavior change related to prescribing psychotropics.

A small proportion of prescribers has been found to account for a large proportion of outlier prescriptions. In Missouri, on average, 300 prescribers out of 11,000 account for more than 50% of the outlier prescriptions identified each month.

Examining the Program

The data sources for a recent study of the BPM in Missouri were Missouri HealthNet claims—pharmacy, inpatient, and outpatient—and the mailing data produced from the BPM intervention. HealthNet recipients whose physicians received a BPM intervention mailing during the first two consecutive mailings of calendar year 2004 were used as cases for this analysis. Recipients who had evidence of a nursing home claim, who were not continuously eligible, or whose physicians had received a mailing prior to these months were excluded from the analysis. Once these criteria were applied, 1,911 unique cases were identified. To document any contemporaneous trends in either admissions or payments for patients receiving behavioral medications in Missouri during the study, we constructed a comparison group (n = 1,911) using the propensity scoring technique.

The analysis focused on two primary periods of interest: (1) preexposure, defined as six months prior to the mailed intervention, and (2) postexposure, defined as six months after the mailed intervention. The primary outcomes of interest in this study were hospitalizations (calculated in rates, mean number per patient, and total hospital patient days by group) and total nonpharmacy medical service costs (e.g., inpatient and outpatient). The total nonpharmacy charges for each recipient were calculated by adding the claim totals from the inpatient and outpatient claims files. Pharmacy claims were excluded from the analysis of total costs per patient to ensure that increases or savings in pharmacy costs did not mask changes in access to or use of inpatient or outpatient services.

Table 1 displays the intervention cases’ demographics. This study found statistically significant differences between the pre- and postexposure periods for all of the primary outcomes of interest—rates of hospitalizations, mean number of admissions to a hospital, total patient hospital days, and total nonpharmacy charges (table 2). There were no detectable changes in the outcomes within the comparison group between the time periods, which indicates that there were no time influences on admissions or payments during the time period of analysis.

Two major findings emerged from this study. First, the BPM physician-oriented intervention is associated with a decrease in hospitalizations, as evidenced by reductions in the overall rates of admission, the mean number of admissions per patient, and the total patient days. Second, there was an overall reduction in the total average nonpharmacy cost of care for inpatient and outpatient services for HealthNet recipients. As hypothesized, the BPM intervention does not cause a disruption in care, and it appears to play a role in the overall reduction in patients’ hospital utilization and cost of care.

The most likely explanation for the BPM intervention's resulting in better care outcomes, measured by using hospital utilization and nonpharmacy costs of care as proxies, is that any of the prescribing changes made as a result of the intervention are completely individualized by the prescribing physician. The physician is given feedback based on his own prescribing patterns and is encouraged to adhere to a set of recognized best practices within his own practice of medicine. The prescribing physician is not held to any mandatory interventions at the patient level, as is done with preferred drug lists or fail-first mechanisms. Patients appear to experience better care outcomes, supporting the conclusion that the prescribing recommendations outlined in the BPM intervention conform to clinical best-practice guidelines.

TABLE 1. Characteristics of intervention cases (n = 1,911)

 

Mean

Standard Deviation

Min

Max

Age (years)

38

18.11

1

94

Gender

Frequency

Percentage

   

Male

797

42%

   

Female

1,114

58%

   

Race

Frequency

Percentage

   

White

1,652

86%

   

Nonwhite

213

11%

   

Unknown

46

3%

   

Medicare/HealthNet dually eligible

Frequency

Percentage

   

Yes

1,103

58%

   

No

808

42%

   

TABLE 2. Changes in hospital utilization and cost of care between pre- and postexposure periods for intervention cases (n = 1,911)

 

Preexposure

Postexposure

Difference

Percentage of recipients admitted to a hospital

     

Intervention

16.8%

9.5%

−7.3%*

Comparison

15.3%

15.2%

−0.1%

Mean number of hospital admissions

     

Intervention

0.31

0.16

−0.15*

Comparison

0.32

0.30

−0.02

Total hospital days for all cases

     

Intervention

3,494

1,681

−1,813*

Comparison

4,785

4,097

−688

Average total patient charges incurred (nonpharmacy)

     

*p< 0.001

Intervention

$6,347

$5,109

−$1,238*

Comparison

$5,946

$5,634

−$312

With an intervention that attempts to align prescribing habits with best practices or clinical guidelines, there are many potential barriers to physician compliance. These include lack of knowledge by the physician, low self-efficacy, believing the result will be negative outcomes, and disagreement with best practices for particular patient populations.11,12 The factors and barriers that influence prescriber adherence to these best-practice recommendations and clinical guidelines should be further researched.

There are some additional observations from the study findings. The BPM intervention does appear to identify the HealthNet population's costliest patients. BPM offers a means of utilizing existing health claims data that is consistent with the recommendations by the President's New Freedom Commission on Mental Health in implementing evidence-based practices in medication management and using technology to improve the coordination of mental healthcare.

Medicare Part D's Impact

More than half of the study's intervention cases were dually eligible for Medicare and HealthNet, and their care may be affected by the abrupt transition to Medicare Part D coverage. With Part D's rapid implementation, there is some concern that an effective intervention such as BPM might be compromised, since the Medicare Modernization Act (MMA) makes no requirement for and provides no incentive to the new pharmacy benefit providers to make pharmacy data available to HealthNet programs for monitoring and improving the quality of patient care.

There are also concerns that cost-containment strategies (e.g., restricted formularies with preferred drug lists, physician prior authorizations, prescription limits, generic substitutions, and increases in patient copayments) will be implemented under Medicare Part D. This study's findings indicate that an intervention that attempts to align prescribing patterns with best-practice guidelines does not disrupt the continuity of care. There appears to be an advantage to allowing the practitioner and patient the opportunity to select the most effective treatment without formulary restrictions. Future research should be done to examine the intervention's direct effect on health and utilization outcomes.

Study Limitations

This study design's limitations offer opportunities for future research. The findings are just one state's outcomes. Therefore, to make broad generalizations across other or all HealthNet programs, the findings should be validated through the analysis of other states’ HealthNet claims data. And there was no detailed analysis of whether the prescriber changed the patient's medications as a result of the intervention. The assumption is that the intervention led to a change in medication management; however, this was not confirmed, and any inferences about whether the prescriber changed his prescribing habits over time or the extent to which this happened must be made with caution.

Conclusion

Missouri has a useful tool for identifying outlying prescribing habits for psychiatric medications and an effective intervention, both clinically and economically, which aligns prescribing with best practices. The technology of the BPM program helps to improve utilization and decrease medical service costs for the state's high-cost HealthNet recipients. Future policy considerations and decisions should focus on strategies that do not disrupt the continuity of care, either during transition or during steady-state operation.

Acknowledgment

The Behavioral Pharmacy Management program is offered through a service contract between Comprehensive NeuroScience, Inc., and Eli Lilly and Company.

John E. Byrd, RPh, MBA, is Director of Outcomes Research at Comprehensive NeuroScience, Inc. Joseph Parks, MD, is Medical Director at the Missouri Department of Mental Health George Oestreich, PharmD, MPA, is Director of Pharmacy Programs at the Missouri Division of Medical Services. Richard Surles, PhD, is Executive Vice-President of Comprehensive NeuroScience, Inc.

References

Sidebar

In Missouri, on average, 300 prescribers out of 11,000 accounts for more than 50% of the outlier prescriptions identified each month.

For more on the BPM program, see the April 2005 issue of Behavioral Healthcare Tomorrow, p. 22.

back to top


Missouri Mental Health HealthNet Pharmacy Partnership Saving Missouri Millions, Recognized as National Model

Jefferson City, MO – The Missouri Mental Health HealthNet Pharmacy Partnership, an alliance of the Division of Medical Services (DMS), the Department of Mental Health (DMH) and Comprehensive NeuroScience Inc. (CNS), has received the 2006 American Psychiatric Association’s (APA) Bronze Achievement Award for its success in improving the quality of prescribing practices for psychiatric medications and patient outcomes.

The Partnership, founded in 2003, aligns psychiatric prescribing practices and has saved Missourians an estimated $7.7 million in HealthNet pharmacy costs.

"The national recognition is truly an honor, but our pride comes from knowing we've established a better way to help Missourians with mental health problems manage their illness and better manage our limited resources," said George Oestreich, Deputy Director of the Division of Medical Services. "The partnership has improved the quality of psychiatric prescribing, improved clinical outcomes and saved millions of taxpayer dollars."

Studies revealed that many of Missouri’s HealthNet patients were receiving care that wasn’t in line with best practice standards including multiple prescriptions for a single patient and inconsistent dosage amounts.  Through the partnership, DMS, DMH and CNS routinely examine pharmacy claims to determine the prescribing patterns of psychiatrists and primary care physicians.  DMH then shares the results along with current best practice standards to encourage modification of prescribing patterns.  This work has improved the quality of psychiatric prescribing and clinical outcomes in addition to saving the state millions.  A 2005 study revealed that inpatient admissions and hospitalization stays dropped by nearly 50 percent after prescribers received intervention messages.

“So far, this partnership has produced nothing but positive results for HealthNet patients dealing with psychiatric issues,” said Joe Parks M.D, Medical Director, Department of Mental Health.  “We are working to extend the success of this program in other ways including piloting similar programs specifically addressing children with attention deficit hyperactivity disorder and those with bipolar disorder and complex needs.”

The federal Center for HealthNet and Medicare Services identified Missouri’s partnership program as a national model.  Twenty-four states have implemented the same or similar approach to managing psychiatric care through HealthNet.

back to top


Mental Health Pharmacy Project Receives National Award

Jefferson City, MO., OCT. 26, 2006 – The American Psychiatric Association (APA) has awarded its 2006 Bronze Achievement Award to the Missouri Mental Health HealthNet Pharmacy Partnership for success in improving the quality of prescribing practices for psychiatric medications and patient outcomes. The project, funded through a contract between Eli Lilly and Company and Comprehensive NeuroScience Inc. (CNS), is an alliance of the state Department of Social Services’ Division of Medical Services, the state Department of Mental Health, and CNS.

The Missouri Mental Health HealthNet Pharmacy Partnership Project was created to align psychiatric prescribing practices with national standards. The partnership program, formed in 2003, has contributed to at least $7.7 million in HealthNet pharmacy costs savings.

“This partnership is a model for reducing hospitalizations, containing pharmacy costs and reducing polypharmacy, and maintaining open access to psychiatric medications through collaboration and education,” said Joe Parks, M.D., Medical Director for the Missouri Department of Mental Health.  “It has produced positive results for HealthNet patients dealing with psychiatric issues. We are working to extend the success of this program in other ways, including piloting similar programs specifically addressing children with attention deficit hyperactivity disorder and those with bipolar disorder and complex needs.”

The goals of the program are to improve patient adherence and outcomes, contain pharmacy costs, and maintain access to psychiatric medications without resorting to preferred drug lists, fail-first approaches, or other restrictive practices. The project assumes that prescribing consistent with nationally recognized best-practice standards will lower overall health care costs and that prescribers will voluntarily adhere to nationally standards once informed. Several outcomes studies have shown that the educational program has helped to reduce inpatient admission and days hospitalized by nearly 50 percent after prescribers received intervention messages.

The partnership routinely analyzespharmacy claims, comparing them with a set of quality indicators that signal questionable prescribing patterns.  DMH then shares the results along with current best-practice standards to encourage modification of prescribing patterns.  This work has improved the quality of psychiatric prescribing and clinical outcomes, in addition to saving the state millions.

“The national recognition is truly an honor, but our pride comes from knowing we've established a better way to help Missourians with mental health problems manage their illness and better manage our limited resources," said George Oestreich, Deputy Director of the Division of Medical Services.

The federal Center for HealthNet and Medicare Services has identified the program as a national model.  Twenty-four states have implemented the same or similar approaches to managing psychiatric care through HealthNet.

The Department of Mental Health serves Missourians by working to prevent mental disorders, developmental disabilities, and substance abuse; by treating, habilitating, and rehabilitating persons with those conditions; and by educating the public about mental health.

back to top


First Mailed Intervention to Physicians Slowed Rate of Increase in Pharmacy Costs~ 10/12/2007

Jeffrey Veach, M.S. 1 2 ; Joseph J. Parks, M.D. 3 4; Harold Carmel, M.D. 1 5; Jack Gorman, M.D. 1; John Docherty, M.D.1 6

Supported by funding from Comprehensive NeuroScience, Inc.

Abstract

This study assessed the effect of mailed physician intervention messages on the rate of change in psychotropic medication costs. A first mailed intervention regarding 16,962 patients (adults continuously eligible for Missouri HealthNet in the study period 2002-2005 receiving psychotropic medications) was sent to the patient’s physician between 6/03 and 11/04. The rate of change in psychotropic medication costs for the study period before the intervention was compared to the rate of change for the study period after intervention.

Average cost/patient/month was calculated for each patient using HealthNet claims data. The analysis was based on a repeated measures analysis of covariance using mixed model methodology, using data from the first 11 mailings. Within the model, rates of change were calculated and analyzed. A statistically significant difference (p<0.0001) was observed in the rate of change before and after the intervention in each of the first 11 mailings.

For the first mailing, the rate of spending increase pre-intervention was $94/12 months; post-intervention, the rate of spending increase fell to $16.50 per 12 months. Estimated savings in the first mailing group (N=2013) was $898/patient during the first year after intervention (p<.0001, 95% CI: $780, $1016). Total estimated savings due to the first mailing = $1.8 million.

Given the limited resources in public mental health systems, it is important to find ways to improve the prescribing of psychotropic medications, promote best practices, reduce hospitalizations and improve consumer recovery. The Missouri Mental Health HealthNet Pharmacy Partnership Project has implemented a state-wide initiative to improve medication practices, using educational mailings targeted to physicians who trigger quality indicators related to best practices. This study assessed the effect of the first mailed message regarding a patient to physicians about their psychotropic medication prescribing practices (“intervention”) on the rate of change of pharmacy, hospital and outpatient costs in a state HealthNet system. The study population was adults receiving psychotropic medications who were continuously eligible for Missouri HealthNet in the study period 2002-2005, about whom an intervention was mailed to the patient’s physician between June 2003 and November 2004.

Three populations were studied: 1) All patients for whom a first intervention was mailed (the “Direct Effect” population, N = 16,962); 2) all patients not mailed on whose physician received a mailing regarding a “Direct Effect” patient (the “Collateral Effect” population, N = 42,960); and 3) a subset of the “Direct Effect” population diagnosed with schizophrenia (the “Schizophrenia Subpopulation,” N = 6,310). Pharmacy claims data were available for all three populations; for the “Schizophrenia Subpopulation,” inpatient and outpatient service claims data were also available.

For each patient, the rate of change in the outcome measure for the entire 2002-2005 study period before the first intervention was compared to the rate of change following the intervention. Average cost per patient per month was calculated for each patient using HealthNet claims data. The analysis was based on a repeated measures analysis of covariance using mixed model methodology, using data from the first 11 batches of mailed interventions (each batch is referred to as a “Cohort”). Within the model, rates of change were estimated and analyzed. Average cost per patient per month was estimated for each patient within each mailing cohort, using HealthNet claims data, based on the model.

A statistically significant difference (p<0.0001) was observed in the rate of change before and after the intervention for behavioral pharmacy costs in each of the first eleven mailing cohorts in all three populations.

A statistically significant difference (p<0.0001) was observed in the rate of change before and after the intervention for non-behavioral pharmacy costs in each of the first 11 cohorts in the “Direct Effect” population, for 6 of the 11 cohorts in the “Schizophrenia Subpopulation,” and for 8 of the 11 cohorts in the “Collateral Effect” population (1 more cohort was significant at the p<.05 level).

For the “Schizophrenia Subpopulation” patients, data were also available for in- and outpatient costs, number of hospital admissions and number of bed-days. In the year following intervention, there were significant overall inpatient cost savings across all cohorts ($799 per patient per year). A statistically significant difference (p<0.05) was observed between the rate of change before and after the intervention for outpatient costs in 9 of 11 cohorts. Across all 11 cohorts, there was a significant savings in outpatient costs ($277 per patient per year), and a significant decrease in admissions (0.132 per patient per year) and bed days (1.2 per patient per year).

Estimated total cost reductions for the year following each patient’s first intervention totaled $36.5 million. Behavioral pharmacy costs were reduced 12.4% in the “Direct Effect” population and 6.1% in the “Collateral Effect” population. In the “Schizophrenia Subpopulation” patients, inpatient costs were reduced by 24.1% (with a 22.8% reduction in admissions) and outpatient costs were reduced by 3.8%.

These data indicate that mailed interventions to physicians about their psychotropic drug prescribing practices can reinforce best practices, reduce hospitalizations, and help state mental health authorities realize considerable savings in pharmacy, hospital and outpatient costs.

References

Parks J, Surles R. Using best practices to manage psychiatric medications under HealthNet. Psychiatr Serv. 2004;55:1227-1229.

Ning A, Dubin WR, Parks JJ: Pharmacy costs: Finding a role for quality. Psychiatric Services 2005;56:909–91.

Andersson K, Petzold MG, Sonesson C, Lonnroth K, Carlsten A: Do policy changes in the pharmaceutical reimbursement schedule affect drug expenditures?

Interrupted time series analysis of cost, volume and cost per volume trends in Sweden 1986-2002. Health Policy. 2006; 79:231-243

back to top


Applying Evidence-Based Medicine to Prescribing Practices in Community Mental Health Centers ~ 10/12/07

Joseph J. Parks, M.D.; George Oestreich, PharmD; Harold Carmel, M.D.; Paul Stuve, Ph.D.

Supported by funding from Comprehensive NeuroScience, Inc.

©2007 Comprehensive NeuroScience, Inc. All Rights Reserved.

Community Mental Health Center

The goal of the program is to improve patient outcomes by improving psychiatric prescribing practices, improving continuity of care across multiple prescribers and improving patient adherence to medication treatments for patients in Missouri’s HealthNet program. Secondary goals include containing pharmacy costs and maintaining access to them through the open formulary of psychiatric medications. The program method and interventions are based on the following principles: prescribing and pharmacy utilization management decisions should be based on data instead of anecdote; (2) interventions should make use of existing data sets and support the current prescribers and; (3) interventions should be respectful of physician/patient autonomy and minimize unintended consequences.

Prescription drugs’ costs and the overall HealthNet prescription drug benefit have received much legislative attention during the past few years, primarily because of state budget shortfalls.1  States have implemented a variety of cost-containment strategies, including restricted formularies with preferred drug lists, physician prior authorizations, prescription limits, generic substitutions, and increases in patient co-payments.1  Simultaneously healthcare managers have struggled to implement programs that align psychiatric prescribing more closely with evidence-based practices. Dissemination of practice guidelines and implementation of treatment algorithms have been cumbersome and difficult, resulting in limited applicability.

As an alternative to preferred drug lists, fail-first approaches, case management, or prior authorizations for control of cost of psychiatric medications, and to provide a more user friendly approach to implementation of evidence-based practices the Behavioral Pharmacy Management (BPM) intervention − a clinical analytic product created by Comprehensive NeuroScience, Inc. (CNS) − was designed as a quality-improvement tool that also produces cost savings by aligning outlier physician prescribing practices with best practices.2  The intervention is predicated on profiling, benchmarking, and modifying physicians’ prescribing practices through an educational intervention in an effort to bring prescribing into alignment with best-practice guidelines. The assumption is that the intervention results in decreased hospitalization rates and use of hospital services − a recognized outcome for interventions −and this subsequently will decrease the patient's overall cost of care.3, 4

The BPM evaluates HealthNet pharmacy claims for all mental health medications to identify prescribing patterns that are inconsistent with national, evidence-based best prescribing practices. Evidence based and expert consensus medication practice guidelines from the peer-reviewed literature are used to identify medication prescription patterns that are usually inconsistent with best practice.

Prescription drug claims from the state’s HealthNet program are analyzed monthly to identify quality indicators such as:

All physicians who are identified as having potential deviations from best practice guidelines as outlined in the quality indicators above receive a mailed intervention that includes:

In addition to the specific patient physician communications, these doctors receive regular information bulletins about special topics related to mental health medications, such as behavioral health medication for children. Physicians who continue to experience the same issues over time are offered a peer consultation to discuss prescribing practices. The project assumes that prescribing consistent with nationally recognized best practice standards will lower overall health-care costs and that prescribers will voluntarily adhere to national standards when they know what they are. This program was the recipient of the 2006 APA bronze achievement award.5

Community Mental Health Center (CMHC) Behavioral Health Prescribing Quality Improvement Program:

Missouri’s CMHCs serve the most complex-need HealthNet patients with serious mental health disorders. Since their patient population is far more behaviorally disabled than other

HealthNet recipients it was important that reporting mechanisms be uniquely developed for the CMHCs that allow them to focus on the improvement of their prescribing and treatment processes. Following the inception of the original project intervention described above CMHC’s in Missouri requested receiving reports regarding prescribing practices and patterns by psychiatrist treating their clients. The CMHC’s information would be helpful for improving prescribing practices, meeting accreditation requirements (DUR), and assessing prescribe or performance. In 2004, Abbott Laboratories funded development of a unique CMHC reporting system that allows benchmarking among the CMHCs who serve comparable patients and promotes improvement of behavioral health prescribing practices for complex need public mental health patients. Initial analysis of CMHC prescribing compared to general practice are shown at the center of this poster.

A new CMHC approach was developed shown below:

The CMHC product is a modified version of the Behavioral Pharmacy Management (BPM) product, designed specifically to provide CMHC administrators with timely and relevant information on the prescribing practices of psychiatrists in their agency.

The main objective of the CMHC product is:

The primary tactics include:

The CMHC product does not include direct contact with patients. The mailings are sent to the CMHC directors, who review the prescriber packets and take appropriate action. All educational materials are based on research findings and expert consensus opinion. No product or treatment recommendations are made.

The benchmark metric utilized was the total number of psychotropic medication prescriptions involved in a quality indicator divided by the total number of psychotropic medication prescriptions by that prescriber or associated with that clinic. Thus the benchmark is the portion of prescriptions involved in a quality indicator out of all prescriptions that potentially could have been involved in a quality indicator. The benchmark metric allows prescribers or CMHCs to see where they fall in the overall range of practice as compared to their peers while controlling for differences in size of practice. The individual prescriber (titled Executive Summary) and CMHC Benchmark Reports are shown to the right.

The CMHC pharmacy management reports with separate reports for adults and children were mailed quarterly beginning September 2004. In 2006, funds from Missouri and Eli Lilly continue to fund the program.

Outcomes

Outcomes were evaluated by following the benchmark metric for all CMHCs as a group over time. Both the adult patient population and the child patient population show a downward trend over time during a period of time during which polypharmacy and high-dose utilization were increasingly common nationally especially for children. The marked decrease between December 05 and March 06 is due to implementation of the Medicare part D pharmacy benefit which removed approximately 50% of persons eligible due to disability from Missouri HealthNet coverage. The increase noted after September 2006 coincides in time with Missouri

HealthNet regaining the ability to capture pharmacy data from Medicare part D drug plans. Data recaptured from Medicare part D plans is included in the analysis to allow those patients to benefit from the improvement and practice.

Discussion

While practice guidelines, medication algorithms, and physician CME allow for dissemination of research evidence and expert consensus regarding what the standard of practice in prescribing ought to be there is little or no available information regarding the actual standard of practice in prescribing psychiatric medications especially at the individual agency and prescriber level. This approach provides that important feedback information allowing better informed judgment by prescribers and the agencies that employ them. The reports provide a tool for prescribers to discuss variations in practice among themselves and for non-prescriber clinic managers to discuss variations in practice with prescribers. This has resulted in a reduction in prescribing practices that are usually inconsistent with evidence based and expert consensus recommended practice.

FOOTNOTES

1. Elam L, Crowley J. HealthNet prescription drug policies: Early findings from a survey of state HealthNet programs. Washington D.C.:Kaiser Commission on HealthNet and the Uninsured, July 2003.

2. Parks J, Surles R. Using best practices to manage psychiatric medications under HealthNet. Psychiatr Serv 2004; 55:1227-9.

3. American College of Mental Health Administration. Accreditation Organization Workgroup. Interim report: A proposed consensus set of indicators for behavioral health. Pittsburgh:American College

of Mental Health Administration, 2001.

4. Bond GR, McGrew JH, Fekete DM. Assertive outreach for frequent users of psychiatric hospitals: A meta-analysis. J Ment Health Adm 1995; 22:4-16.

5. Bronze Award: Missouri Mental Health HealthNet Pharmacy Partnership Project — A Successful Partnership to Improve Prescribing Practices. Psychiatr Serv 2006;57(10):1528-1529.

back to top


American Specialty Health and INSPIRIS win top honors in URAC’s Best Practices in Consumer Empowerment and Protection Awards

Esteemed judges spotlight 22 winning programs for setting new benchmarks in consumer-focused care

Contact: Karla Hurter
Phone: (703)319-0957 or khurter@health2resources.com

Washington, D.C. March 25, 2008 – URAC recognized two programs with Best Practices Awards at a ceremony Tuesday evening spotlighting the 22 award recipients of its first-ever Best Practices in Consumer Empowerment and Protection Awards.

American Specialty Health was named the Best Practices Award winner in consumer/patient safety for its program, “Reduction in Regional Variation of X-ray Utilization.” Programs in this category are broadly related to patient or consumer safety issues such as safe, effective, patient-centered, timely, efficient and equitable care. Outcomes for these programs are limited to health/clinical metrics.

INSPIRIS and Mercy Care Plan of Arizona won the Best Practices Award for“INSPIRIS CarePlus Nurse Practitioner-Led Care” in the integrated care coordination category. Programs in this category are designed to coordinate or manage the care of patients/consumers among different, often isolated, “agents” of care.

“Winning a Best Practices Award is an important signal to the marketplace, a mark of distinction that will resonate in the purchaser community and ultimately among consumers,” said Alan P. Spielman, URAC’s president and CEO. “This awards competition and conference recognize the programs that are blazing new trails in consumer protection and empowerment and can be used as models for innovation and quality throughout the health care management industry.”

In all, URAC honored 22 winners for excellence among entries from health care management, health information technology, health plan and pharmacy benefit management organizations. Entries were judged by a distinguished panel of industry experts in three categories: consumer decision support, consumer/patient safety, and integrated care coordination. Programs were selected as winners for their ability to measurably demonstrate an impact on consumer empowerment and/or protection, as well as their potential for wide-spread implementation of the program by other organizations.

“URAC is breaking new ground with this first-ever competition that draws from organizations across the health care management spectrum,” Spielman said. “These are effective, innovative practices that can be duplicated to the benefit of consumers and health care purchasers across the country.”

Winners of URAC’s Best Practices in Consumer Empowerment and Protection Awards are:

Honorable Mention:

Winners in the Health Care Management Category:

Winners in the Health Information Technology Category:

Winners in the Health Plan Category:

Winners in the Pharmacy Benefit Management Category:

Best Practices Awards:

About URAC

URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation and education programs. URAC offers a wide range of quality benchmarking programs and services that keep pace with the rapid changes in the health care system, and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in establishing meaningful quality measures for the entire health care industry. For more information, visit www.urac.org.

back to top