New program examines psych Rxs for Missouri Medicaid patients


Funded by Lilly, Missouri Medicaid reviews mental health prescriptions to improve care and cut costs



New program examines psych Rxs for Missouri Medicaid patients

A new partnership between Missouri's Department of Mental Health (DMH) and Department of Medicaid has implemented a program that examines the prescribing practices of the state's 21,000 physicians who routinely write prescriptions for behavioral health medications. In an effort to improve the quality of care to the 220,000 mental health patients on Medicaid and reduce costs, the program evaluates the Rxs of some 80 selected medications by comparing them with established good practice guidelines and alerting practitioners of problem areas.

The new project, called the Missouri Mental Health Medicaid Pharmacy Partnership Program, involves a monthly review of data from Medicaid Rxs filled for certain drugs. Researchers look at indicators such as inaccurate dosages, untimely refills, multiple medications of the same type, patients receiving the same prescriptions from more than one provider, rapid switching of medications, and children receiving high numbers of psychiatric medications. When discrepancies are found, physicians are notified with educational letters.

"We've seen physicians change their practice," said Joseph Parks, M.D., medical director of DMH, and lead psychiatrist on the project. "Each letter sent out is followed up with a phone call," he said. "Doctors like knowing what their peers are doing, and prefer to have a dialogue regarding the problem areas rather than being told what to do. They like to have clinical points raised, and they'd rather have this than being handed a formulary list of acceptable drugs."

Following an initial review of 24 months of Medicaid pharmacy claims in May 2003, when the program began, Missouri's DMH found that 75% of Rxs for behavioral medications were already being prescribed correctly. This program will focus on the small group of physicians with ongoing prescribing problems in an effort to change their behavior and save money, said Parks. Of Medicaid pharmacy costs in Missouri, 33% are spent on mental health drugs.

"The most common problem is patient nonadherence, which translates into a late refill," said George L. Oestreich, Pharm.D., director of the Missouri Medicaid pharmacy program. "We also see a significant amount of what appears to be off-label use of the atypical antipsychotics for sedation." Oestreich, who helps review the data and has five other pharmacists working with him, focuses on the outlier prescriptions that don't comply with guidelines and participates in the preparation of the 3,000 letters sent out each month for each group of indicators.

"Typically only about half of the physicians sent letters one month will be on the list again the following month," said Parks. "In some cases, we need to send letters and call for several months until things are resolved," he said. Prescribing will continue to be monitored to determine whether the educational materials have made an impact. Physicians who fail to respond will be encouraged to consult with well-respected psychiatry experts for additional education and support. "It's an ongoing process," said Oestreich. "As some problems are cleared, new ones emerge."

The evaluation of Rxs involves comparing data to several indicators that are based on national standards for psychiatric practice. The guidelines were reviewed and endorsed by an advisory panel of leading Missouri psychiatrists and mental health advocates. Comprehensive Neuroscience Inc., a firm that specializes in helping to improve prescribing practices of behavioral health medications, is assisting in coordinating the project and funding is being provided by a grant from Eli Lilly & Co.

Since the program's inception, the state has seen improvements, said Parks, but "we probably won't know exactly where we are for another six months. We started sending out letters in April and are just now noticing fewer patients taking more than one antipsychotic. We've also seen a slower increase in the rate of spending on psychiatric medications," he added.

Researchers hope to get additional funding from Lilly that will help finance the program until the spring of 2005.

Heidi Belden, Pharm.D.


Heidi Belden. New program examines psych Rxs for Missouri Medicaid patients. Drug Topics Nov. 3, 2003;147:44.

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