Pharmacy Utilization Management

Getting at Cost via Quality

The Issue

More patients on meds

More meds per patient

More cost per med

Limited evidence of benefit

Doctors

Pharma

Leadership“Drug therapies are replacing a lot of medicines as we used to know it.”

George W. BushOctober 17, 2000

Comments from St. Louis, Missouri Presidential Debate

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.

Our Duty = The Usual Accepted Standard of Practice

EVIDENCE

+

EXPERT CONSENSUS

+

ACTUAL PRACTICE

DISCUSSION AND DELIBERATION

Enforcing Good Practice

Documentation Standards

Restrictive Formulary

Algorithms

Documentation Standards

One or more target symptoms for each medication

Target symptoms that are measurableTarget symptoms scored at each visitExplicit time frame for re-evaluation.

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

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).

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

SSRI Preference Algorithm

Depression OCD PMDD Bulimia PTSD

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/Lexpro

X

Luvox X

FDA Indications for SSRI Antidepressants

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

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

Redressing Bad Practice

Outlier Case Review

Guideline Congruence Review

Benchmarking

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

Under Utilized Medications

First line Lithium

Second line – (doesn’t mean never)ClozapineTricyclic Antidepressants1st Generation Antipsychotics

Outlier Case Review

Patients on most individual medications

Patients on 3 or more in the same class

Patients on most prn’s

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?

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

Practice Pitfalls

Rapid changesOver reliance on medicationUsing multiple new medications before

trying mono-therapy old medicationsUnder-dosingNot contacting community prescriber

Commonly Under Dosed Medications

Lithium

Valproic Acid (Depakote)

Tricyclic Antidepressants

Antipsychotic Non-Responders

Adequate Duration: 6-8 weeks4 Possibilities

Dose too lowDose too highWon’t help at any dose

Approach: Use Clozapine or Haldol and check serum level

Essential Input from Community Prescriber

For each individual medicationWhat’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?