Transcript 2003 Annual Institute for Governors` Health Policy Advisors

CHCS
Center for
Health Care Strategies, Inc.
Clinical Pharmacy Management Initiative
Achieving Results in Medicaid Pharmacy
Management
Anna Fallieras
Director, State Purchasing Programs
September 2003
CHCS
Center for
Health Care Strategies, Inc.
Presentation Overview
• Current State Environment
• Development of Clinical Pharmacy Management
Initiative (CPMI)
• Case Studies
• State Resources
CHCS
Center for
Health Care Strategies, Inc.
Budget Crises Forcing States to Target
Medicaid Cutbacks
$48.8
$30.7
$14.5
SOURCE: National Association of State Budget Officers; Reuters
CHCS
Center for
Health Care Strategies, Inc.
Medicaid Spending
• Total annual State General Fund spending= $467
Billion
• Medicaid accounts for approximately 15% of annual
State General Fund expenditures ($70 Billion)
• Prescription drugs account for nearly 10% of state
Medicaid spending ($25 Billion)
• Medicaid and State Employee Health Plans account
for 20% of total prescription spending in the U.S. (
$28 Billion)
CHCS
Center for
Health Care Strategies, Inc.
Medicaid Prescription Drug Growth Rate is
Significant
Managed Care
15.9%
Home Care
11.7%
Nursing Facilities
7.9%
Prescription Drugs
19.7%
Outpatient Hospital, Clinic
5.5%
Physician, Lab, X-Ray
1.7%
Inpatient Hospital
5.2%
All Medicaid Services
8.8%
0.00%
5.00%
10.00%
15.00%
Average Annual Rate of Growth 1998-2000
SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute
analysis of HCFA-64 data.
20.00%
CHCS
Center for
Health Care Strategies, Inc.
Pharmacy Accounts For A Growing
Percentage Of State Medicaid Expenditures
• Pharmacy Costs: Double digit increases in pharmacy
expenditures, due to price inflation, utilization, and types of
prescriptions used.
• Enrollment Growth: Rising Medicaid enrollment due to
past program expansions and increase in numbers of
uninsured, and changing mix of Medicaid population have
contributed to prescription drug spending increase.
• Management: Until recently, insufficient use/execution of
pharmacy and clinical management strategies.
CHCS
Center for
Health Care Strategies, Inc.
Containing Prescription Drug Costs
Is a Stated Priority
Number of states reporting:
45
FY2002
FY2003
37
32
27
25
22
17
9
8
4
Controlling
drug cost
Reducing/
Freezing
Provider
Payment
Reducing/
Restricting
Eligibility
Reducing
Benefits
SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by
Health Management Associates, June 2002.
Increasing
Co-Payments
CHCS
Center for
Health Care Strategies, Inc.
States Have Access To A Range Of Mechanisms That
Manage The Pharmacy Benefit
• Pharmacy management strategies fall into several categories:
Price (e.g., PDLs, Rebates, etc.)
Drug Mix (e.g., generic substitution, step therapy, etc.)
Utilization (e.g., quantity limitations, DUR, etc.)
Clinical Management (e.g., profiling, pharmacy case management,
disease management, etc.)
• Currently focus is on preferred drug lists with supplemental rebates to
bring down price and change drug mix.
CHCS
Center for
Health Care Strategies, Inc.
Strategies Based Only On Price and Mix May
Come Up Short
• Use of prior authorization/preferred drug list with supplemental
rebates will certainly result in immediate program savings.
o Price/Mix: Does result in immediate reduction in cost of drug and a share shift
to lower cost, therapeutically equivalent drugs.
o Utilization: May not result in appropriate care and may affect quality of care.
o Clinical Management & Quality: Does not address quality health issues related
to complex, chronically ill populations resulting in potential expenditures in
other service areas, e.g., inpatient, ER, physician visits, issues related to
beneficiary confusion, etc.
CHCS
Center for
Health Care Strategies, Inc.
Strategies Based Only On Price and Mix May
Come Up Short (cont.)
• Incorporating additional utilization and clinical management
strategies as part of a comprehensive approach can result in additional
savings while protecting and improving patient care:
o Improved information to providers and consumers
o Improved disease monitoring and timeliness of interventions
o Improved compliance with proven “best practices”
o Improved coordination and communication among caregivers and patients
o Measurable improvements in outcomes and costs
CHCS
Goal of the Clinical Pharmacy
Management Initiative
Center for
Health Care Strategies, Inc.
To assist states in developing clinical pharmacy
management initiatives that have the potential to
generate Medicaid program savings while improving
beneficiary care
Center for
Health Care Strategies, Inc.
CHCS
Clinical Pharmacy Management Initiative
(CPMI)
• Center for Health Care Strategies - Health Strategies
collaboration to:
o Build the case for integrating quality into pharmacy cost
management strategies
o Identify models that pursue both clinical improvement and cost
reduction goals
o Provide a framework for states to develop new clinical pharmacy
management initiatives
o Provide technical assistance to states
Note: CPMI was developed in response to a request from State Medicaid Directors and with expert input from the CHCS Managed Care
Solutions Forum on Pharmacy.
CHCS
Center for
Health Care Strategies, Inc.
What is Clinical Pharmacy Management?
Current efforts largely focused on
Pharmacy Case Management
Improved coordination and communication
among caregivers and patients
Improved compliance with proven “best
practices”, Rx therapies
(e.g., AZ, MS, UT)
Improved information to providers and consumers
Physician Profiling
(e.g., FL, TX, WA)
Improved disease monitoring and timeliness of
interventions
Measurable improvements in outcomes and costs
CHCS
Center for
Health Care Strategies, Inc.
Pharmacy Case Management
• Identify and manage patients that meet at least one of the
following criteria:
o Generate high Rx costs
o Take high number of Rx
o Have a certain chronic disease(s)
• Program typically triggered when beneficiary:
o Reaches certain drug limit
o Generates claims above set level
o Is diagnosed with a particular disease
• Interventions can vary significantly:
o Patient managed by healthcare professional
o Direct mail/disease education campaigns
CHCS
Center for
Health Care Strategies, Inc.
Physician Profiling
• Technique used to identify providers who prescribe outside
guidelines
• Typically triggered through drug utilization reviews
• Intervention might include
o Education of prescribing protocols
o Pharmacist consultation to review patient-specific issues
CHCS
CPMI: Framework
Center for
Health Care Strategies, Inc.
CHCS
Center for
Health Care Strategies, Inc.
Case Studies
• In-depth profile of 4 models that optimize the CHCS
framework
o Washington Therapeutic Consultation Service
o Texas Medication Algorithm Project
o Americhoice of PA Behavioral Pharmacy Management System
o North Carolina Nursing Home Polypharmacy Initiative
CHCS
Center for
Health Care Strategies, Inc.
Washington State
Therapeutic Consultation Service (TCS)
Identification/
Stratification
Clinical Goals
Patients with 5th brand in calendar month or
non-preferred drug.
Promote appropriate pharmaceutical care and
promote cost-effective drug therapies.
Outreach/
Intervention
Pharmacists review entire drug regimen and
perform any necessary prior authorization.
Average 8,545 edits/month needing
intervention.
Monitoring/
Evaluation
Savings for FY 2002 estimated at $8.75
Million (5 months of TCS). Net savings for
first 12 months was $31 Million.
Center for
Health Care Strategies, Inc.
CHCS
Texas Medication Algorithm Project
(TMAP)
Identification/
Stratification
Clinical Goals
Providers of patients diagnosed with
schizophrenia, major depression, and
bipolar disorder identified through claims
data.
Improve clinical outcomes, reduce use of
inappropriate medications, standardize care
throughout the state.
Outreach/
Intervention
Algorithms given to providers; patient and
family education describes prescribing
guidelines; documentation of prescribing
practices and clinical outcomes.
Monitoring/
Evaluation
Two-year longitudinal study showing
“superior clinical outcomes”, such as
improved cognitive functioning for
schizophrenics. Economic analysis will be
released later this year.
Center for
Health Care Strategies, Inc.
CHCS
AmeriChoice of PA Behavioral Pharmacy
Management System
Identification/
Stratification
Physicians with “outlier” prescribing
patterns are identified using an evidencebased algorithm of physician prescribing
patterns.
Clinical Goals
Reducing duplications and inappropriate
dose patterns.
Outreach/
Intervention
Physicians are sent letter and guideline
materials, followed by “peer-to-peer”
education call re: evidence-based
guidelines and best practices.
Monitoring/
Evaluation
Five quality edits are monitored for
improvement. During 2001-2002, an 11%
increase in behavioral health pharmacy
costs among all prescribing MDs; MDs
receiving the intervention had no related
cost increases.
CHCS
North Carolina Nursing Home
Polypharmacy Initiative
Identification/
Stratification
Clinical Goals
Outreach/
Intervention
Monitoring/
Evaluation
Center for
Health Care Strategies, Inc.
Patients in select nursing homes 18+
medications in 90 day period.
Reduce inappropriate drugs, duration of
therapy, dosing, duplications, adverse
reaction, and non-preferred drugs.
State-hired physician/pharmacist teams
review patient drug regimens, determine if
a drug therapy problem exists, recommend
a change and perform follow-up to verify
change. 8559 out of 9208 patients
required recommendations.
74% of recommendations acted upon.
Cumulative savings from intervention
expected to total $15 million this year.
CHCS
Center for
Health Care Strategies, Inc.
Design and Implementation Issues
• How will those targeted for the intervention be identified,
e.g., claims data, physician referral?
• What will be the basis for stratifying the intervention
population, e.g., risk assessment, costs, other metrics?
• Who will participate in the development of the program
objectives and quantifiable clinical goals?
• Will the program be rooted in evidence-based practices and
are they currently available?
CHCS
Center for
Health Care Strategies, Inc.
Design and Implementation Issues (cont)
• How will provider and member participation be encouraged?
• How will any additional services be reimbursed, e.g., performancebased, risk-based, service-based?
• How will the enrollment process be designed, e.g., opt-in versus optout?
• Will the program be designed and administered in-house or through a
vendor?
• What measures will be established to identify process achievements,
cost savings, and clinical outcomes based on identified program
objectives?
CHCS
Center for
Health Care Strategies, Inc.
CPMI Technical Assistance Products
• Report comparing fiscal impact of state pharmacy programs to health
plan pharmacy management efforts (January 2003)
• Introductory report outlining the Clinical Pharmacy Management
Initiative and Best Practices (April 2003)
• Issue brief on nursing home pharmacy (Draft Available)
• Issue brief on behavioral health pharmacy (November 2003)
• Purchasing Institute Sessions for Medicaid Directors and Executive Staff
(November 2003)
• CHCS State Technical Assistance Series (Winter 2003)
CHCS
Center for
Health Care Strategies, Inc.
Additional Information
For additional pharmacy resources and inquiries
on CPMI, please contact:
Anna Fallieras or Sylvia Couvertier
(609) 895-8101
www.chcs.org