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February 1, 2006
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One state's program gives physicians a “heads up” about their prescribing practices

Prescription drugs account for only 11% of national healthcare spending, but expenditures for drugs have been growing at an annual rate of 15%, which is higher than the increases seen in either physician and clinical services or hospital care.1 This increase can be attributed to growth in prescription drug use, newer and more expensive drug therapies that replace older and less expensive ones, and price increases by pharmaceutical manufacturers. Of these contributing factors, the increase in overall utilization has had the greatest impact on spending and was responsible for 42% of the overall increase in prescription drug spending between 1997 and 2002.1

Prescription medications to treat psychiatric conditions are among the most costly drugs for Medicaid programs. The cost of antidepressants and antipsychotics has been reported to be nearly 20% of Medicaid prescription drug expenses, with all psychiatric medications accounting for one-third of those expenses.2,3

States React

These prescription drugs’ costs and the overall Medicaid prescription drug benefit have received much legislative attention during the past few years, primarily because of state budget shortfalls.4 States have implemented a variety of cost-containment strategies, including restricted formularies with preferred drug lists, physician prior authorizations, prescription limits, generic substitutions, and increases in patient copayments.4 In addition to programs aimed mainly at cost containment, interventions (e.g., case management for complex patients) have been adopted to improve quality of care and moderate long-term expenses.

States may modify the design of their Medicaid prescription drug benefit, and they may choose to adopt one or several of these approaches to combat growing costs. Forty-six states adopted at least one new cost-containment strategy during 2003 in an effort to control prescription drug spending within their Medicaid program.2 Adoption of these policies is not always done empirically, and exemptions sometimes are made for certain drugs or drug groups, such as psychiatric medications. Studies have indicated that traditional pharmacy utilization-management interventions (such as step algorithms, prior authorizations, prescription limits, and restricted formularies) undertaken solely with a cost-reduction goal in behavioral healthcare can have extremely negative effects on people with serious mental illnesses.5–7 A recent review of pharmacy-utilization management initiatives for psychiatric medications concluded that a greater focus on quality may be effective at containing costs while avoiding unintended negative consequences.8

Missouri's Approach

As an alternative to preferred drug lists, fail-first approaches, case management, or prior authorizations for psychiatric medications, the Behavioral Pharmacy Management (BPM) intervention (a clinical analytic product created by Comprehensive NeuroScience, Inc.) was designed as a quality-improvement tool that also produces cost savings by aligning outlier physician prescribing practices with best practices.3 The intervention is predicated on profiling and modifying physicians’ prescribing practices through an educational intervention in an effort to bring prescribing into alignment with best-practice guidelines. The assumption is that the intervention results in decreased hospitalization rates and use of hospital services—a recognized outcome for interventions—and this subsequently will decrease the patient's overall cost of care.9,10

The BPM is the result of the Mental Health Medicaid Pharmacy Partnership program implemented in Missouri in the first quarter of 2003.3 Each month, the prescription drug claims for the Medicaid program are analyzed by comparing them to multiple quality indicators indicative of questionable prescribing patterns, such as:

  • prescribing three or more antipsychotics to one patient

  • multiple prescribers for antipsychotics for one patient

  • a patient's failure to refill an antipsychotic

  • prescribing unusually high or low doses of antipsychotics

  • prescribing two or more sedative-hypnotics or anxiolytics

  • polypharmacy in several therapeutic classes

  • prescribing three or more psychotropics for children

Physicians identified as having potential deviations from best-practice guidelines (as outlined in the quality indicators) are mailed an intervention, which includes a “quality-consideration” letter that outlines the potential deviation, a 90-day pharmacy claims history of patients in their practices to whom the selected indicator applies, and best-practice guidelines and empiric references related to the clinical issue. This mailed intervention is the primary mechanism within the program that encourages physician behavior change related to prescribing psychotropics.

A small proportion of prescribers has been found to account for a large proportion of outlier prescriptions. In Missouri, on average, 300 prescribers out of 11,000 account for more than 50% of the outlier prescriptions identified each month.