Pharmacy Utilization Management Getting at Cost via Quality

1. Pharmacy Utilization Management Getting at Cost via Quality

2. The Issue • More patients on meds • More meds per patient • More cost per med • Limited evidence of benefit

3. Doctors

4. Pharma

5. Leadership “Drug therapies are replacing a lot of medicines as we used to know it.” George W. Bush October 17, 2000 Comments from St. Louis, Missouri Presidential Debate

6. Pharmacy Management Guiding Principles” • Manage through data, not intuition or anecdote. • 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; • Monitorfor both planned and unplanned consequences. • 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.

7. Our Duty = The Usual Accepted Standard of Practice EVIDENCE + EXPERT CONSENSUS + ACTUAL PRACTICE DISCUSSION AND DELIBERATION

8. Enforcing Good Practice • Documentation Standards • Restrictive Formulary • Algorithms

9. Documentation Standards • One or more target symptoms for each medication • Target symptoms that are measurable • Target symptoms scored at each visit • Explicit time frame for re-evaluation.

10. Key Arguments • 2nd generation antipsychotics are all unique in their mechanism of action • Psychiatrists can’t predict which patients will benefit most from which mechanism

11. Key Conclusions • Don’t withdraw access to a medication that’s clearly proven beneficial to that patient. • Do require trying less costly options first if there’s no proof of likely superiority in that particular patient (example: strong family history of benefit).

12. Difference Among SSRI’s • Safety – “remarkably similar” * • Tolerability – “only modest differences” • Efficacy – “not any difference” • Relapse prevention ‘ “amazingly consistent” * Except drug-drug interactions from “Clinical Pharmacology of SSRI’s”Sheldon Preskorn 1996

13. SSRI Preference Algorithm FDA Indications for SSRI Antidepressants

14. SSRI Preference Algorithm Automatic Exemptions (Approval) • Any SSRI they are currently on • Any SSRI there is a record of prior treatment with • Paxil if there is a prior diagnosis of PTSD, Social Phobia, or General Anxiety on record • Zoloft if there is a prior diagnosis of PTSD on record • Concomitant use MAOI, Thioridazine, or Opiates

15. Exemptions (Approvals) by Request • Physician reports and documents a diagnosis of PTSD for Zoloft usage • Physician reports and documents a diagnosis of PTSD, Panic Disorder, Social Phobia, or Generalized Anxiety for Paxil usage • Physician reports and documents prior usage of that SSRI with good efficacy • Physician reports patient has been on that SSRI at least 30 days prior • Physician reports and documents first degree relative had good treatment response to other SSRI

16. Redressing Bad Practice • Outlier Case Review • Guideline Congruence Review • Benchmarking

17. Best Practice Information • Expert Consensus Guideline Series www.psychguides.com • Texas Medication Algorithms www.dshs.state.tx.us/mhprograms/TMAP.shtm • American Psychiatric Association www.psych.org/psych_pract/treatg/pg/prac_guide.cfm

18. Under Utilized Medications • First line • Lithium • Second line – (doesn’t mean never) • Clozapine • Tricyclic Antidepressants • 1st Generation Antipsychotics

19. Outlier Case Review • Patients on most individual medications • Patients on 3 or more in the same class • Patients on most prn’s

20. Guideline Congruence Reviews • Have patients on more than one antipsychotic had trial of monotherapy Clozapine? • Have patients on more than one antidepressant had trial of monotherapy TCAs? • Have patients on more than one new anticonvulsant had trials of Lithium and Valproate at adequate doses? • Have patients on more than one new antipsychotic had trial of monotherapy old antipsychotic?

21. Benchmarking • Choose indicators • More than 5 psychotropic • More than 1 antipsychotic • More than 2 mood stabilizers • More than 1 antidepressant • For each prescriber divide number of patients hitting one or more by all patients on medication class • Rank order by portion • Discuss range in medical staff meeting

22. Practice Pitfalls • Rapid changes • Over reliance on medication • Using multiple new medications before trying mono-therapy old medications • Under-dosing • Not contacting community prescriber

23. Commonly Under Dosed Medications • Lithium • Valproic Acid (Depakote) • Tricyclic Antidepressants

24. Antipsychotic Non-Responders • Adequate Duration: 6-8 weeks • 4 Possibilities • Dose too low • Dose too high • Won’t help at any dose • Approach: Use Clozapine or Haldol and check serum level

25. Essential Input from Community Prescriber • For each individual medication • What’s the target symptom? • How convinced are you that it’s helpful? • Is it essential for successful treatment? • How reliable is the patient in taking meds? • What would they like addressed during hospitalization?