Anti-psychotic Medication
in Children, Adolescents and
Foster Care:
Too Many, too Much, and too Young
Medicaid Medical Directors Learning
Network (MMDLN) and State Efforts
Jeffery Thompson, MD, MPH
Chief Medical Officer
Washington State Health Care Authority
1
Discuss How States are Working Toward
Access to Quality Affordable Care
1) Discuss How States Turn data into
Information
2) Discuss the 16 State Study
3) Discuss the Resource Guide
4) Discuss the MedNet – a 7 State
Study with Rutgers
5) Next Steps
2
The Problem Statement: Unexplained Variation is an Issue
2004 regional variation in clients using four or more mental
health drugs by county; WA decided to do something
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Variation Drives Health Care Costs:
Lack of Medication Adherence appears to
Drive Hospitalizations and ER use
Antipsychotic Adherence
Relationship between length of time gap since exhausting last refill and outcomes over the next 6 months
Community Psych
IP Admissions
ED Visits
Medical Inpatient
Admissions
Per 1,000 Member Months
Per 1,000 Member Months
Per 1,000 Member Months
313
61
37
188
38
23
156
16
14
No Gap
0 Days
Short Gap
1-16 Days
POSSESSION RATIO ANALYSIS
Medical Assistance Cost PMPM
Long Gap
17+ Days
No Gap
0 Days
GROUP 1
| Bottom 50%
Short Gap
1-16 Days
Long Gap
17+ Days
GROUP 2
No Gap
0 Days
| 50th – 80th Percentile
Short Gap
1-16 Days
GROUP 3
Long Gap
17+ Days
| Top 20 Percent
Ratio < 1.22
Ratio 1.22 to 2.08
Ratio > 2.08
$1,100
$1,341
$1,753
4
How can States Work Together?
In 2008 the MMDLN invited a small number of
states to discuss anti-psychotic medication
management and whether comparing systems and
policies:
 An informal data-sharing agreement between 16 states to pull
and share utilization and demographic data with Rutgers
University
 A survey of state programs and practices to categorize policies,
statutes, and utilization controls related to mental health
medications
 A process to share state practices based on a systematic process
(best, promising, emerging, and unknown)
 A publication committee made up of State Medical and Mental
Health Directors to write a Resource Guide
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Antipsychotic Medication Use in Children and
Adolescents in 16 States and 12 million children:
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Every State had a
great data point
and a wart!
Min (%)
Median (%)
Max (%)
Data are not risk adjusted for population composition thus statistical
comparisons were not possible
6
What’s in Your Rate?
Percent of Children Using APs
Each State Received a Feedback Report
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
2004
Washington
2005
Minimum
2006
2007
Mean
Maximum
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States that appeared to have lower rates on
specific measures and could be consulted
include:
 MO, MA, PN and TN had lower gaps in care
 IL, WA, and NY had lower overall AP use rates
 CA, NY, and OR had lower AP use rates in children <5 years
 OR, ME, and OK had lower high dose rates of APs
 NH, WA, AL had lower multiple use rates of APs (>2 APs)
 OR, WA, and IL had lower multiple use rates of Mental Health
Drugs (>4MHDs)
 MO, TN ,and ME had lower gap in days of APs (>20 days of Gap)
 OR, CA, and WA had lower foster care use rates of APs
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Antipsychotic use: Key Findings and Outcomes
Washington State
Department of Social
& Health Services
http://rci.rutgers.edu/~cseap/MMDLNAPKIDS.html.
9
Antipsychotic use: Key Findings and Outcomes
Washington State
Department of Social
& Health Services
http://rci.rutgers.edu/~cseap/MMDLNAPKIDS.html.
10
What is a
Best
Practice?
11
Antipsychotic Medication Use in Children and
Adolescents: A Resource Guide and Workbook
http://rci.rutgers.edu/~cseap/MMDLNAPKIDS.html.
12
Antipsychotic Medication Use in Children and
Adolescents: A Resource Guide and Workbook
http://rci.rutgers.edu/~cseap/MMDLNAPKIDS.html.
13
Second opinions
work to reduce
misuse and overuse
of drugs
14
Numbers for Washington State
Executive Summary: CY2007
• Total users: 4,978 (1.4%) of enrolled kids used an
Antipsychotic (dropping on a monthly basis through
January 2010)
• Growth trends: Antipsychotic users grew 25% and
unit costs grew 38% from 2004 to 2007
• Antipsychotic use in the very young: 187 AP users
are less than 5 years old
• High dose: 499 (10%) of users are prescribed high
doses of Antipsychotics
• Multiple AP use: 896 (19%) of users had two or more
Antipsychotic prescriptions
15
Numbers for Washington State
Executive summary: CY2007 (Cont.)
•
Multiple Mental Health Drug use: 621 (2.3%) of kids are prescribed 5 or
more mental health drugs
•
Adherence: 1,588 (39%) had a gap in Antipsychotic use of greater than
20 days
•
Provider types: Antipsychotics were prescribed by Psychiatrists (45%),
PCP (34%) and ARNP (21%)
Multiple Mental Health Drug use: 621 (2.3%) of kids are prescribed 5 or
more mental health drugs
•
•
Adherence: 1,588 (39%) had a gap in Antipsychotic use of greater than
20 days
•
Provider types: Antipsychotics were prescribed by Psychiatrists (45%),
PCP (34%) and ARNP (21%)
16
PAL’s web
resources
highly
utilized
(>300,000 hits)
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Other Aspects of PAL Services
• Free psychiatric education conferences hosted
minimum of 4 times a year in our rural
communities
– 656 PCP attendees at 28 educational events
• Free, expert reviewed care guideline
– Distributed to over 2,000 WA physicians
– Downloaded over 10,000 times
• Quarterly consult audits to ensure evidence
based advice is consistent with the care guide
18
MedNet– A Seven State Collaborative
Collaborative to ensure that resources are
maximized and that outcomes and indicators are
consistent
Feedback : with Predictive Health Polypharmacy, Dose, Adherence, Generics ER,
Rehospitalizations
Tools: Educational materials for Providers
Medication
Adherence, Reducing Rehospitalizations & Avoidable
ER Use
Sharing: Best Practices are shared across
clinics in the collaborative
Measure Improvements: All providers are
receiving feedback reports, outlier prescribers
are having Peer-to- Peer conversations
19
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How do we get better?
20
Is there Too Much Variation in Care?
Less
variation with
application of
data and
asking why?
2007
2011
21
How do we ensure children are given the right
treatment at the right time for the right reason?
Questions?
Jeff Thompson, MD, MPH
Chief Medical Officer
Washington State Health Care Authority
360-725-1612
Jeffery.thompson@hca.wa.gov
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