This document discusses the role of managed care pharmacy in mental health disease state management. It finds that incorporating mental health case management into managed care can improve quality of life and reduce costs. Case management programs help ensure adherence to maintenance therapy for mental illnesses like depression. The document advocates that managed care organizations underutilize strategies like medical management, formulary decisions, and education for mental health, despite the high prevalence and costs of untreated mental disorders.

1. Mental Health and Managed
Care
Leah Smith
Duquesne University
Pharm D Candidate, Class of 2012

2. Objectives
• Review the role of managed care pharmacy in
disease state management.
• Summarize the incidence, prevalence, and
treatment of mental health disease states.
• Identify roles managed care can have in
mental health disease state maintenance.
• Summarize cost benefits of incorporating
mental health case management into
managed care pharmacy.

3. Disease State Case Management in
Managed Care
• Traditionally utilized to manage severe and complex
member cases or complex populations costing high
amounts of health care dollars.
– Heart disease, diabetes, asthma, COPD, etc
• Most insurers target between 3-5% of the insured
population with case management efforts.
• The overall purpose of any medical management
program is to show a risk reduction, utilize all resources
available for individuals or populations, portray an
increase in quality of life in the population and quality
of services of the company, and build a knowledge base
not only for company purposes but for the advancement
of healthcare everywhere.

4. Reasons to Incorporate Medical
Management Programs
• Marketplace
– NCQA
• Health Care Cost
– Prevention and Maintenance
• Provider Benefit
– Efficient, relevant, etc
• Member Quality of Life
• Data Retrieval

5. Components of Case Management
Programs
• Organization
– Staff: adequate and qualified
• Policies and Procedures
– Case identification, implementation, coverage,
treatment plan, documentation, etc
• Evaluation
– Monitoring, improved quality of life, etc
• Interdepartmental Involvement
– Physicians, benefit manager, pharmacy records, etc

6. Pharmacist’s Role in
Medical Management
• Outlet for case managers’ medication related
questions.
• Role in development of Policies and
Procedures.
• Evaluation of appropriate medication
guidelines usage for individual cases.
• Gathering and evaluating data to recognize a
health, cost, or quality of life benefit from the
management program.

7. Mental Health in the U.S.
• 1 in 4 Americans suffer
from a short term
mental disorder in any
given year.
– Eating disorder, anxiety,
etc
• 60% of patients with
mental disorders go
untreated.
• National shortages
– Psychiatric beds and
psychiatrists

8. Mental Health Treatment Strategies
• Multiple types of mental health issues identified:
– Anxiety, Mood Disorders, Psychotic Disorders, Eating
Disorders, Addiction, Personality Disorders, etc
• All have the same general step therapy to treatment,
monitoring, and maintenance:
– Medications: psychiatrist
• Following specialized guidelines
• Adding, subtracting, and managing ADRs as necessary
– Psychosocial therapy: psychologist/therapist
• Outpatient care for those with SMI
– Evaluation on a specified mental exam
• EX: Global Assessment of Functioning
– CONTINUING MEDICATION COMPLIANCE!!

9. Medications used in Mental Health
• Antipsychotics
– Typicals: Haldol*, Thorazine*, Trilafon*, Prolixin*
– Atypicals:Clozaril, Zyprexa*, Risperdal*, Seroquel, Geodon*, Abilify*, Invega*
• Anti-depressants
– SSRIs: Celexa, Lexapro, Paxil, Prozac , Zoloft, Luvox, low dose Effexor
– SNRIs: Pristiq, Cymbalta, Savella, Effexor,
– TCAs: Elavil, Anafranil, Norpramin, Adapin, Tofranil, Pamelor
– Adjunct: Remeron, Wellbutrin, Buspar, Trazadone
• Mood Stabilizers
– Depakote, Lamictal, Lithium, Tegretol, Keppra, Neurontin
• Anti-anxiety agents
– Buspar
– Vistaril
– Benzodiazepines: Valium, Xanax, Ativan, Klonopin
• Sleep agents
– Lunesta, Ambien, Trazadone,

10. Mental Health and Pharmacy
• Formulary considerations
– Injections vs. Oral
• Evaluation of Compliance
– Patient education
– Identification of ADRs
• Case Management
– Supplemental support to case managers
– Supplemental support to psychiatrists

11. Cost of Mental Health
• In 2006, $57.5 billion was
spent on health care
services for patients with
mental health.
• 6% of the population has a
SMI causing a loss of $193
billion in earnings per year.
– People with mental health
issues earn 40% less than
the average person in good
mental health.
• $400 billion lost per year
for untreated addiction
disorders.

12. Cost of Mental Health
• Community based services are the most cost
effective outlet to manage mental illnesses.
– Consisting of medication, medical management, and
outpatient therapy.
– The average per day cost of community based services
is $12
• Due to budget cuts in mental health and national
shortages of psychiatrists increased funds are
utilized for state hospital beds, jail/prison time,
and emergency room visits

15. TEAMcare Study: Funded by the NIMH
• Purpose was to see a benefit in endpoints of
other chronic diseases with increased mental
health attention in care.
– There is a high prevalence of depression with multiple
comorbid diseases
• Randomized into PCP (control) or TEAMcare (PCP
+ nurse case manager)
• Using computerized pharmacy records to study
adherence.
• Currently being investigated for cost benefit in a
large health plan

16. Conclusion
• Mental health is a high cost consuming and
highly prevelant disease state that can be
controlled with appropriate management.
• It is in the interest of the payer company and
the patient to ensure adherence to
maintenance therapy.
• Incorporation of medical management in the
form of case management, formulary
decisions, education, etc are underutilized in
mental health.

17. Work Cited
• Rosenbergh, Ira & Sajdak, Mary “Case Management” Medical
Management. Managed Care Resources Inc.
http://www.mcres.com/mcrmm06.htm.
• Kingsbury, Kathleen “Tallying Mental Illness’ Cost”. TIME Magazine.
May 2008.
http://www.time.com/time/health/article/0,8599,1738804,00.html
• National Institute of Mental Health (NIMH). www.nimh.nih.gov.
• Katon WJ, Lin EHB, Von Korff M, Ciechanowski P, Ludman EJ, Young
B, Peterson D, Rutter CM, McGregor M, McCulloch D. Multi-
condition collaborative care for chronic illnesses and depression.
New England Journal of Medicine. Dec. 30, 2010.