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

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

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

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).

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

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?

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