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Anti-psychotic Medication in Children, Adolescents and

Foster Care:

Too Many, too Much, and too Young

Medicaid Medical Directors Learning Network (MMDLN) and State Efforts

Jeffery Thompson, MD, MPHChief Medical OfficerWashington State Health Care Authority

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Discuss How States are Working Toward Access to Quality Affordable Care

1) Discuss How States Turn data into

Information

2) Discuss the 16 State Study

3) Discuss the Resource Guide

4) Discuss the MedNet – a 7 State

Study with Rutgers

5) Next Steps

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The Problem Statement: Unexplained Variation is an Issue

2004 regional variation in clients using four or more mental health drugs by county; WA decided to do something

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Variation Drives Health Care Costs: Lack of Medication Adherence appears to

Drive Hospitalizations and ER useAntipsychotic Adherence

Relationship between length of time gap since exhausting last refill and outcomes over the next 6 months

Community Psych I P Admissions

Per 1,000 Member Months

ED VisitsPer 1,000 Member Months

Medical I npatient Admissions

Per 1,000 Member Months

POSSESSION RATIO ANALYSIS GROUP 1 | Bottom 50% GROUP 2 | 50th – 80th Percentile GROUP 3 | Top 20 Percent

Ratio < 1.22 Ratio 1.22 to 2.08 Ratio > 2.08

Medical Assistance Cost PMPM $1,100 $1,341 $1,753

SEPTEMBER 17, 2009

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38

61

No Gap0 Days

Short Gap1-16 Days

Long Gap17+ Days

156

188

313

No Gap0 Days

Short Gap1-16 Days

Long Gap17+ Days

16

23

37

No Gap0 Days

Short Gap1-16 Days

Long Gap17+ Days

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How can States Work Together?

In 2008 the MMDLN invited a small number of states to discuss anti-psychotic medication management and whether comparing systems and policies: An informal data-sharing agreement between 16 states to pull and

share utilization and demographic data with Rutgers University

A survey of state programs and practices to categorize policies, statutes, and utilization controls related to mental health medications

A process to share state practices based on a systematic process (best, promising, emerging, and unknown)

A publication committee made up of State Medical and Mental Health Directors to write a Resource Guide

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Data are not risk adjusted for population composition thus statistical comparisons were not possible

Antipsychotic Medication Use in Children and Adolescents in 16 States and 12 million children:

0%5%

10%15%20%25%30%35%40%45%50%

Min (%)

Median (%)

Max (%)

Every State had a great data point

and a wart!

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What’s in Your Rate?

00.5

11.5

22.5

33.5

44.5

2004 2005 2006 2007Perc

ent o

f Chi

ldre

n U

sing

APs

Washington Minimum Mean Maximum

Each State Received a Feedback Report

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States that appeared to have lower rates on specific measures and could be consulted include: MO, MA, PN and TN had lower gaps in care IL, WA, and NY had lower overall AP use rates CA, NY, and OR had lower AP use rates in children <5 years OR, ME, and OK had lower high dose rates of APs NH, WA, AL had lower multiple use rates of APs (>2 APs) OR, WA, and IL had lower multiple use rates of Mental Health Drugs (>4MHDs) MO, TN ,and ME had lower gap in days of APs (>20 days of Gap) OR, CA, and WA had lower foster care use rates of APs

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Washington StateDepartment of Social

& Health Services

Antipsychotic use: Key Findings and Outcomes

http://rci.rutgers.edu/~cseap/MMDLNAPKIDS.html.

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Washington StateDepartment of Social

& Health Services

Antipsychotic use: Key Findings and Outcomes

http://rci.rutgers.edu/~cseap/MMDLNAPKIDS.html.

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What is a Best Practice?

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Antipsychotic Medication Use in Children and Adolescents: A Resource Guide and Workbook

http://rci.rutgers.edu/~cseap/MMDLNAPKIDS.html.

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Antipsychotic Medication Use in Children and Adolescents: A Resource Guide and Workbook

http://rci.rutgers.edu/~cseap/MMDLNAPKIDS.html.

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Second opinions work to reduce

misuse and overuse of drugs

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Numbers for Washington State

• Total users: 4,978 (1.4%) of enrolled kids used an Antipsychotic (dropping on a monthly basis through January 2010)

• Growth trends: Antipsychotic users grew 25% and unit costs grew 38% from 2004 to 2007

• Antipsychotic use in the very young: 187 AP users are less than 5 years old

• High dose: 499 (10%) of users are prescribed high doses of Antipsychotics

• Multiple AP use: 896 (19%) of users had two or more Antipsychotic prescriptions

Executive Summary: CY2007

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Numbers for Washington State

• Multiple Mental Health Drug use: 621 (2.3%) of kids are prescribed 5 or more mental health drugs

• Adherence: 1,588 (39%) had a gap in Antipsychotic use of greater than 20 days

• Provider types: Antipsychotics were prescribed by Psychiatrists (45%), PCP (34%) and ARNP (21%)

• Multiple Mental Health Drug use: 621 (2.3%) of kids are prescribed 5 or more mental health drugs

• Adherence: 1,588 (39%) had a gap in Antipsychotic use of greater than 20 days

• Provider types: Antipsychotics were prescribed by Psychiatrists (45%), PCP (34%) and ARNP (21%)

Executive summary: CY2007 (Cont.)

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PAL’s web resources

highly utilized

(>300,000 hits)

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Other Aspects of PAL Services• Free psychiatric education conferences hosted

minimum of 4 times a year in our rural communities– 656 PCP attendees at 28 educational events

• Free, expert reviewed care guideline– Distributed to over 2,000 WA physicians– Downloaded over 10,000 times

• Quarterly consult audits to ensure evidence based advice is consistent with the care guide

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MedNet– A Seven State Collaborative

Collaborative to ensure that resources are maximized and that outcomes and indicators are consistent

Feedback : with Predictive Health Poly-pharmacy, Dose, Adherence, Generics ER, Rehospitalizations

Tools: Educational materials for Providers Medication Adherence, Reducing Re-hospitalizations & Avoidable ER Use

Sharing: Best Practices are shared across clinics in the collaborative

Measure Improvements: All providers are receiving feedback reports, outlier prescribers are having Peer-to- Peer conversations

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How do we get better?

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Is there Too Much Variation in Care?

Less variation with application of data and asking why?2007

2011

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How do we ensure children are given the right treatment at the right time for the right reason?

Jeff Thompson, MD, MPHChief Medical OfficerWashington State Health Care Authority360-725-1612Jeffery.thompson@hca.wa.gov

Questions?