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;
 Monitor for 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
Depression OCD PMDD Bulimia PTS
D
Panic Social
Phobia
General
Anxiety
Fluoxetine
(Prozac/
Sarafem)
X X X X X
Zoloft X X X X
Paxil X X X X X X
Celexa/Lexpr
o
X
Luvox X
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?