Mental Health Medication Use in Washington
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Mental Health Medication Use in Washington

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A report on the use of mental health medications in Washington State

A report on the use of mental health medications in Washington State

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  • Many users who have contact with mental health services manage to conceal their use from mental health professionals. What is the appropriateness of psychotropic medication use patterns among ... Consider population-based carve-outs to address unique mental health.

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  • 1. A Big Unknown : Mental Health Medication in WA Jeffery Thompson, M.D. Chief Medical Officer Washington State Medicaid Community Mental Health Mtg Yakima WA June 14, 2008
  • 2. Today’s agenda:
    • Review Medicaid “spends, trends and use” of mental health medication
    • Discuss local and national variations in clinical practices
    • Discuss what happens when we work together and link data and programs
  • 3. Washington State: FFS & managed care Healthy Options clients are children, TANF ( * ) families or pregnant women * Note : TANF – Temporary Assistance for Needy Families Region Support Networks
  • 4. Why the Concern?
        • Accuracy Diagnoses
          • ( How and who?)         
        • Mental health drug poly-pharmacy & poly-prescribing
          • (Why are these clients more @ risk?)
        • Adherence 
          • ( Are the clients taking their meds? )
        • Regional variations
          • ( Can we find “best practices”?)
        • What about the Highest Risk?
          • (foster care, homeless, substance abuse)                             
        • Coordination and information sharing with the provider
          • ( What information do you need? )
        • Dosing over safety thresholds
          • ( Should there be limits?)       
  • 5.
    • What’s in the News?
  • 6. Groundbreaking new study finds over-diagnosis of bipolar disorder The indications and “off label” use of AAP are rapidly changing and confusing for the prescriber
  • 7. CONCLUSIONS: Current prior-authorizations policies for AAPs do not appear to reduce pharmacy reimbursement -- probably because alternative medications are costly .
  • 8. Are There Conflicts of Interest? Sen. Grassley Issues Report on Conflict-of-Interest Probe Into Improper Payment Disclosures by Three Harvard Psychiatrists      Three well-known psychiatric researchers from Harvard Medical School may have violated federal and educational institution regulations by failing to properly disclose drug industry payments and other conflicts of interest, according to an investigation report published last week by Sen. Chuck Grassley (R-Iowa) in the Congressional Record , the Wall Street Journal reports (Armstrong, Wall Street Journal , 6/9). According to the New York Times , the group's "consulting arrangements with drug makers were already controversial because of the researchers' advocacy of unapproved uses of psychiatric medicines in children" (Harris/Carey, New York Times , 6/8).
  • 9.
    • What’s in the data?
  • 10. Anti-Psychotic drug expenditures Washington State, 2000 - 2007 The AAP class is the No. 1 expenditure for most Medicaid states. The 21% growth in AAP costs is driven by both unit cost and growth in utilization
  • 11. What about Poly-Pharmacy & AAP? One client prescribed 5 AAPs by 5 prescribers in 12 months
  • 12. What About Regional Variation in Washington? Map shows excessive AAP dosing ( * ) in CY 2007 among children (under 18 years old)  * NOTE: Based on dosing thresholds in Texas Foster Care Step Therapy Guidelines
  • 13. What About “Off Label” Use of AAPs Data in Dementia Is there high dosing, poly-pharmacy and poly-prescribing in Dementia?
    • 8,726 clients over 60 years old are on Atypicals .
    • 2,161 or about 25% of these clients show Dementia Dxs. (not necessarily exclusive of other Dxs.)
    • 205 of those clients with a Dementia Dx, exceed 1.5 x the highest study doses.
    Number of Clients using: 1  AAP   = 132 2  AAP  =    61 3  AAP =    11 4  AAP =    1 Number of Doctor’s Prescribing:   1 AAP = 119 2 AAP  =    56 3 AAP =    21 4 AAP =      6 5  AAP =      3 x 1.5 Dose Highest Study Dose AAP Drug 240 mg 160 Ziprasidone 22.5 mg 15 mg Aripiprazole 300 mg 200 mg Quetiapine 3 mg 2 mg Risperidone 22.5 mg 15 mg Olanzepine
  • 14.
    • What does data say across our smokestacks?
  • 15. Opiate Treatment Savings What about ER Use, Pain Meds and Mental Health? INCLUDES persons who are Medicaid-only aged, blind, disabled, presumptively disabled, or General Assistance-Unemployable in Fiscal Year 2002. SOURCE = Medicaid Integration Project database. TOTAL CLIENTS (FY 2002) = 130,274. Average Number of Pain Prescriptions is Highest Among Those Most Frequently Visiting the ER 89% with co-occurring Average Number of Narcotic Analgesic Prescriptions Per Client in FY 2002 Percent Who Received Prescriptions for Pain Among clients in FY 2002 that had. . . NO Emergency Visit ONE Visit 31+ Visits Yes 27% Yes 51% Yes 99% No 73% No 49% Number of Visits to the ER, FY 2002 n = 81,980 n = 19,393 n = 10,765 n = 11,474 n = 4,526 n = 1,607 n = 331 n = 198
  • 16. What are the most dangerous drugs?
  • 17. What about Medicaid Narcotic Deaths and Mental Health? DOH Death Certificate Cause
    • DOH 2004-2006 DOH data matched with Medicaid clients with
    • narcotic prescriptions in the last 3 months of life
    42% of WA Rx Deaths
  • 18. Who are those dying? Washington State, 2004 – 6 (narcotic related deaths in Medicaid – linking 357 death certificates to claims data) Integrating across agencies and data systems is a must because contracts and payment systems do not treat the riskiest clients. This data has sold a narcotic review program and provider support WA Medicaid is 42% of all narcotic related deaths
  • 19. So what works??? Working together works!!!
  • 20. What Happens when DSHS Shares Information with Providers? 12 month prescription history shared for Clients with > 10 narcotic Rx/month 25% reduction in Narcotics, ER is reduced, Hospitalization reduced And cost reduced – when information is shared
  • 21. What Happens When Data Crosses Contractors? Large differences between counties re-hospitalizations compared to Gap in AAP therapy by Mental Health Contractors: How can we learn to use data? * NOTE: 9000 Clients with schizophrenia: Relationships holds for poly-pharmacy (#Rx/year) and Poly-prescriber (#Rxers/year) ER utilization and SNF care rates Looking at data across systems is more informative than by systems
  • 22.
    • There are ~27,000 users of stimulants with 1000 ADHD Second Opinions that resulted in:
      • Rxs for Children less then 5 year old 24%
      • Poly pharmacy use 48%
      • High doses of stimulants 63%
      • Most stimulants in utilization (-0.4 to -35%)
      • There are NO less than 5 year olds on high dose stimulants
      • But there was 150% increase in Focolin
    What Happens when DSHS & Providers Agree on Safety Edits?
  • 23. How do we work together?
    • The PDL list and OHSU reviews
    • Rx.wa.gov
    • Getting a 12 month history of Rx, ER and services
    • http://fortress.wa.gov/dshs/maa/pharmacy/Toolkit.htm
    • Patient Review & Coordination Program
    • http://fortress.wa.gov/dshs/maa/PRR/
    • Getting a DASA services ( 1-800-562-1240 )
    • http://www.dshs.wa.gov/dasa/services/treatment/treatmentexpansion.shtml
    • Opioid Dosing Guideline for Chronic Pain
    • http://www.agencymeddirectors.wa.gov/opioiddosing.asp
    • QUESTIONS!