Most states’ Medicaid programs are under financial pressure as the number of enrollees fluctuates, federal matching funds are threatened perennially, prices of pharmaceuticals steadily rise based on a number of market factors, and ineffective and costly treatments tax limited resources. For help in specifically managing their behavioral pharmacy costs, and to improve quality of care, states such as Alaska, Idaho, Missouri, Oregon, and many others have implemented the Behavioral Pharmacy Management Program (BPMP), which is offered through a three-way agreement among the state Medicaid agency, Comprehensive NeuroScience, Inc. (CNS), and Eli Lilly and Company (whose primary role is to fund the program). State officials in Utah, one of the first states to implement the BPMP, have been particularly innovative in maximizing the BPMP's effectiveness.
The BPMP is an educational service that focuses on bringing prescribers’ practices more in line with evidence-based treatments to improve care quality and reduce costs, says Julie Olson, director of the Bureau of Managed Health Care in the Utah Department of Health. Each month, CNS analyzes Utah's Medicaid data to identify providers whose prescribing practices (such as polypharmacy) trigger selected indicators, as well as providers who are prescribing (probably unknowingly) behavioral health drugs for patients being treated with similar drugs by other prescribers.
The advent of Medicare Part D shifted the population for which the state has pharmacy data and financial responsibility, explains Olson. So beginning this year, the BPMP is focusing more on behavioral drugs prescribed to children and adolescents as well as adults not dually eligible for Medicare and Medicaid.
Based on these data, reports and educational materials are mailed every month to 200 selected providers whose prescribing patterns may be at variance with best-practice guidelines (reports for children/adolescents and adults alternate monthly), as well as to hundreds of providers prescribing behavioral health medications to the same patients. Providers are encouraged to use the data to reevaluate their prescribing practices in light of evidence-based treatments, which are described in the mailings.
The outreach doesn't stop there. Utah has a peer consultant program in which well-respected psychiatrists contact selected prescribers to follow up on the mailings and to discuss prescribing practices. Any provider, in fact, can contact the peer consultants for guidance free-of-charge.
The peer consultants also present data and suggest evidence-based treatments in group settings, which is a very popular form of outreach, according to Kristina Hindert, MD, the medical coordinator of the peer consultant program.
“It's an open forum in which doctors can comfortably talk about these issues,” explains Dr. Hindert. “In a group setting, doctors often are less defensive than when getting a phone call.” It helps, too, that these group sessions are held during regularly scheduled medical team meetings, notes Dr. Hindert.
Dr. Hindert considers the BPMP and the peer consultation service as “a wonderful opportunity to extend how we interact with doctors in educating them about evidence-based treatment, as well as obtain data about whether doctors are using evidence-based treatment.”
Dr. Hindert notes that some providers are hesitant when they first receive mailings from the program, but after hearing from the consultants, they realize how they can really improve the care of their patients, as well as reduce costs. “These are often their most complex and demanding patients, the ones with whom they have the least effective response to medication, and they have great concerns about how they're prescribing,” says Dr. Hindert.
The peer consultants already have had meetings at most of the community mental health centers in the state, and also are meeting with primary care physicians. BPMP administrators are hoping to make continuing medical education credits available for both individual and group peer consultation sessions in the near future.
Figures 1–7 illustrate some of the results of the BPMP in Utah. In general the program is moving in the desired direction. Executive Management Reports indicate significant variance between expected and actual monthly behavioral pharmacy spending, a decrease in monthly behavioral prescriptions per patient for high-risk (targeted) patients, and no increase in monthly behavioral pharmacy claims despite an increase in Medicaid membership. The difference between the expected cost of behavioral health drugs if the BPMP had not been implemented and the actual cost since the program's inception has been particularly noteworthy (figure 5).
Olson says that overall, she sees the BPMP as a quality-improvement endeavor: “Improving the quality of care is the greatest outcome we've had from this program.” The federal government's Substance Abuse and Mental Health Services Administration (SAMHSA) has commissioned Mathematica Policy Research, Inc., to conduct an independent evaluation of Utah's BPMP.