MISSOURI PARTNERSHIP
Children’s Division/DSS
MO HealthNet/DSS
Office of Clinical Officer/DMH
“Policy”
Webster's Dictionary 1966
• “Prudence or wisdom in the management
of public affairs”
• “A definite course or method of action and
selected from among alternatives and in
the light of given conditions to guide and
determine present and future decisions”
“Policy”
Thomas Fuller 1608-1661
“Policy consists in serving God
in such a manner as not to
offend the devil”
4
Be Soft on People
Hard on the Problem
Fisher & Vry “Getting to Yes” 1981
5
What Made it Possible? - Relationships
• Values
– Stability
– Trust
- Transparency
- Common Agenda
• Partners
– The State Medicaid Authority – MO HealthNet
– DMH
– State Budget Office
– Missouri Coalition of CMHCs
– The Missouri Primary Care Association
– Vendors: Xerox, CMT, WIPRO, MIMH
• Data - Use of Health Information Technology to identify
and monitor problems, and assess performance
S.M.R. Covey, The Speed of Trust
Behaviors that Promote Trust
• Character
–
–
–
–
–
Talk Straight
Demonstrate Respect
Create Transparency
Right Wrongs
Show Loyalty
• Competence
–
–
–
–
–
Deliver Results
Get Better
Confront Reality
Clarify Expectations
Practice Accountability
• Character & Competence
• Listen First
• Keep Commitments
• Extend Trust
Strategy for Success –
The “Win / Win” Opportunity
Solve someone else’s problem and they will solve yours
– Physicians – become more data and cost
conscious
– Medicaid – pursue clinical quality
– Dept of Mental Health – help Medicaid manage
utilization and preserve access
– Advocates – work together to identify acceptable
limits and interventions
– Vendors – combat inappropriate use
8
9
Pharmacy Management
“Guiding Principles”
• Manage through data, not intuition or anecdote.
• Monitor for both planned and unplanned consequences.
• Focus management interventions on good evidence, quality treatment
guidelines and compliance with medication plans.
• Don’t establish the primary goal as “cost savings”. Allow cost savings to
be the natural result of evidence based care, quality and adherence to
treatment guidelines;
• Don’t discriminate between physical and behavioral drugs, i.e. don’t
limit behavioral drugs more than you would physical drugs.
• Don’t punish the many, for the sins of the few. Target your
Interventions to outliers who need it, not to compliers who don’t.
10
Missouri’s Behavioral
Pharmacy Management
• Helps improve prescribing practices
• Identifies clinicians whose prescribing patterns
deviate from current clinical best-practices
• Quality Indicators are developed from
– continuous review of medical literature
– consensus guidelines
– nationally recognized clinical panels
Child BPM Program
• 1,367 Missouri children who triggered BPM QI’s in May 2011
and were eligible in October 2011 and April 2-12 were studied.
• From May 2011 to April 2012, behavioral pharmacy costs fell
11% for this group.
• During this time, total pharmacy costs fell 7.5%.
• Most children triggering polypharmacy QI’s in May 2011 were
no longer triggering them in April 2012.
The Quality Indicators™ and analytic methods presented in this document are confidential and proprietary trade secrets of Care Management
Technologies (CMT). This document and its contents may not be used, disclosed, or redisclosed except with the written agreement from CMT.
Child BPM Program
QI #
May
2011
April
2012
% Change May 2011
to April 2012
101
Use of Benzodiazepines for 60 or More Days (Under 18 Years)
325
135
-58%
205
Use of 2 or More Antipsychotics for 45 or More Days (Under 18
Years)
192
76
-60%
510
Use of an Antipsychotic at a Higher Than Recommended Dose for
45 or More Days (Under 18 Years)
165
41
-75%
202
Use of 3 or More Psychotropics for 90 or More Days (6-12 Years)
103
18
-83%
505
Use of Clonidine at a Higher Than Recommended Dose for 45 or
More Days (Under 18 Years)
99
38
-62%
311
Use of an Atypical Antipsychotic in a child four years old or younger
96
19
-80%
417
Multiple Prescribers of the Same Class of Psychotropic Drug for 45
or More Days (Under 18 Years)
92
26
-72%
The Quality Indicators™ and analytic methods presented in this document are confidential and proprietary trade secrets of Care Management
Technologies (CMT). This document and its contents may not be used, disclosed, or redisclosed except with the written agreement from CMT.
Child BPM Program
QI #
May
2011
April
2012
% Change May 2011
to April 2012
205
Use of 2 or More Antipsychotics for 45 or More Days (Under 18 Years)
192
76
-60%
202
Use of 3 or More Psychotropics for 90 or More Days (6-12 Years)
103
18
-83%
106
Use of 2 or More Atypicals and a Stimulant or ADHD Non-Stimulant for
30 or More Days (Under 18 Years)
72
23
-68%
201
Use of 4 or More Psychotropics for 90 or More Days (13-17 Years)
50
10
-80%
511
Use of an Antipsychotic at a Higher Than Recommended Dose and a
Stimulant or ADHD Non-Stimulant for 45 or More Days (Under 18
Years)
26
8
-69%
508
Use of a Stimulant or ADHD Non-Stimulant AND Use of a TCA at a
Higher Than Recommended Dose and for 45 or More Days (Under 18
Years)
9
2
-78%
6
3
-50%
1
0
-100%
1
0
-100%
1
1
0%
461
141
-69%
504
160
167
169
Use of an ADHD Non-Stimulant at a Higher Than Recommended Dose
for 45 or More Days (Under 18 Years)
Use of 2 or More Benzodiazepines for 45 or More Days (Under 18
Years)
Use of 2 or More Tricyclic Antidepressants for 60 or more days (Under
18 Years)
Use of 2 or More Insomnia Agents for 60 or More Days (Under 18
Years)
Total (may include duplicate patients)
The Quality Indicators™ and analytic methods presented in this document are confidential and proprietary trade secrets of Care Management
Technologies (CMT). This document and its contents may not be used, disclosed, or redisclosed except with the written agreement from CMT.
Child BPM Program
• Impact analysis shows $6.77 million in behavioral pharmacy
cost avoidance for the 23,371 child patients continuously eligible
since February 2010 who were subjects of a BPM mailing.
• This is an average of $124.42 per intervened patient per month.
• The patients were followed for an average of 17.5 months postmailing.
The Quality Indicators™ and analytic methods presented in this document are confidential and proprietary trade secrets of Care Management
Technologies (CMT). This document and its contents may not be used, disclosed, or redisclosed except with the written agreement from CMT.
Outlier Pattern 2006-2009
Kids Percentage of Patients
7/09-9/09
9/09-11/09
25.7%
22.5%
2 Antipsychotics
2.5%
2.7%
Hi Dose Antipsychotic
1.8%
2.0%
Antipsychotics < 4 y o
1.3%
1.4%
5 or more
1.8%
1.6%
Total Antipsychotics
Outlier Pattern 2006-2009
Adult Percentage of Patients
7/09-9/09
9/09-11/09
25.7%
23.5%
2 Antipsychotics
5.9%
5.9%
3 Antipsychotics
0.37%
0.38%
Hi Dose Antipsychotic
2.0%
2.6%
2 Benzodiazepines
3.1%
3.1%
Total All Antipsychotics
Use of Antipsychotics in Medicaid Children16 States, 2004-2007
•
•
•
•
•
•
Highest rate of use in Kids under 18 yo
Highest rate of use in Kids under 6 yo
Above median use of multiple psychotropics
Median rate of high dose antipsychotic use
Median rate of multiple antipsychotic use
Fewest Gaps in therapy for antipsychotics
Child Antipsychotic Prevalence Program
The Quality Indicators™ and analytic methods presented in this document are confidential and proprietary trade secrets of Care Management
Technologies (CMT). This document and its contents may not be used, disclosed, or redisclosed except with the written agreement from CMT.
Missouri Initiative for Children
in Foster Care
• There are approximately 10,750 children in
state custody at a given time
• Data pulled
– Top diagnoses were Major Depression,
Adjustment Disorder, Attention Deficit
Hyperactivity Disorder, and Post Traumatic Stress
Disorder
• 28% were on a psychotropic medication
Missouri Initiative
Behavior Pharmacy Management Program
• 20% of children prescribed a medication
triggered at least one quality indicator
– 6.65% were prescribed 5 or more psychotropics
– 3.03% were prescribed two or more antipsychotics
– 6.05% had multiple prescribers for 45 or more days
Past and Current Initiatives
• 2009 - 2011
– Provided Integrated Summary of Care to Foster Care
Case Managers with pharmacy recommendations
– Foster Care Case Managers did not feel qualified to
question prescribers regarding recommendations.
• Currently
– For all children under 5 years old
– PA all psychiatric meds
– Case review by child psychiatrist
Next Missouri Initiative
• Current focus has been on the development of
a second opinion review process
– Initially addressing children on more than 5
psychotropics
– Plans to address use of multiple antipsychotics as
well
– Identification of prescriber with outlier
prescriptions
Missouri Initiative
• Review of records by Board Certified
Child/Adolescent Psychiatrist
• Via teleconference Reviewer discusses best
practices for prescribing of patients
• Prescriber continues to be monitored to
assess for change in prescribing
Missouri Initiative
• Strategies Under Consideration
– Data monitoring/system development
– Clinical edits
• Medication
• Therapies
– Access to Clinical Consultation
– Functional Outcomes
WebNeuro Online Standardized Assessment
1)
2)
3)
4)
5)
45 Questions assessing anxiety, depression, and stress
13 Standardized Cognitive Tests
Standardized scoring for risk, resilience, and social skills
Decision support for diagnosis and treatment
40 minutes to complete, three minutes to receive report
c
Integrative Neuroscience Assessment
[home computer]
Questions [Feeling and Self Regulation] (<5 min)
“I Find it
difficult to
relax”
“I respond best
to positive
feedback”
Objective Cognitive Tasks [Emotion and Thinking] (30 min)
Motor
Tapping
Choice Reaction
Time
Memory
Recognition
Emotion
Identification
Digit Span
Verbal
Interference
Switching of
Attention
Go/No-Go
Delayed
Memory
Recognition
Emotion
Recognition
Continuous
Performance
Test
Maze
English, Hebrew, Mandarin, Arabic, Spanish, Dutch, French, German
WebNeuro Report: Patient’s Sores
Scores range from 0-10,
with 10 being better
Red shading
= clinically significant
c
problem (score of 1)
Orange shading =
problem of borderline
significance (1.5 to 3)
Gray shading =
healthy average
range (3.5 to 7.5)
Green shading = above
average/superior (8 to 10)
Example Reporting of Cognitive Capacities
Reporting averages scores from tests commonly
used to assess specific cognitive and emotional
capacities into a psychological-level score.
In example above, Negativity Bias in assessment
of negative outlook on world and a validated
marker for disorder risk.
Cognitive Reporting: Cognition & Thinking
Objective assessment & reporting of emotional and cognitive processes
Supporting Treatment