Access and Utilization of New Antidepressant and Antipsychotic Medications. C. Utilization Management

Health care payers have turned to utilization review (DUR) as a primary means of quality assurance and cost-containment. All of the payers interviewed maintain some form of utilization review program. DUR monitors providers, identifies outliers (i.e., over/under-prescribers), and screens patients (e.g., high cost cases eligible for disease management). The majority of providers use DUR as an educational tool to encourage good prescribing practices. Several providers use DUR as a monitoring tool to enforce compliance with formulary, PA and treatment guidelines.

• Public Programs

  • HCFA(now known as CMS) performs drug utilization analysis on an ad hoc basis for the mental health therapeutic classes. The findings of HCFA(now known as CMS)'s reviews are not for public distribution. All Medicaid and State Mental Health Agencies perform some type of drug utilization review, in accordance with the requirements OBRA '90. A survey of Medicaid programs found that 14 States perform DUR in-house, 31 contract the process out, and 4 do a combination of the two.¹⁹ A large majority of States (42) perform Prospective DUR (PRODUR) in addition to retrospective DUR.

    The DoD performs DUR through a contract staff. For mental health prescriptions, the goal is to minimize duplicated medications and overdosing. The VA has a national in-house DUR database that is reviewed on a regular basis.

• Private Payers

  • Most PBMs track and monitor drug utilization. The majority of DUR programs run through PBMs are retrospective only (although two PBMs run concurrent DUR). They are either managed in-house or through the main health plan. Quality assurance is the most important goal of DUR, followed by formulary compliance (and reduction of drug costs). DUR is often used to identify physicians who are over- or under-prescribers of medications. This identification helps to target physician education initiatives. Criteria for DUR include assuring appropriate dosage, preventing drug interactions, and formulary compliance. One PBM tracks individual physician utilization patterns rather than tracking utilization at the request level. Another PBM has a quality initiative based upon SSRI compliance.

    MCOs either perform DUR in-house or contract out to PBMs. Clinical pharmacists run the DUR program at one MCO (in-house, prospective, retrospective and concurrent). The goals of DUR are quality assurance (i.e., appropriate use of drugs in a cost-effective manner) and cost minimization. Monitoring of psychotropic medications occurs no differently than for other classes of pharmaceuticals and tracks duplication, overuse, under-use and possible drug interactions. One MCO interviewed has set standards of compliance for both acute and maintenance phase antidepressant treatment. Utilization review found that the majority (65%) of patients receiving antidepressant medication met their standards for acute phase treatment by remaining on the antidepressant during the entire phase, and almost 50% met the six-month long continuation phase standards by remaining on the drug during that time period.

    Employers generally contract out to a PBM or other source for DUR. For these payers, DUR primarily serves as a screening device to identify patients in need of disease management.

    BMHCOs are involved in utilization management for both their public and their private sector clients. However, these organizations focus on the entire scope of care and seek to insure that patients are cared for in the least intensive locus of care that meets their mental health needs.

    Although the use of psychotherapeutics is part of the continuum of care, the BMHCOs are not generally involved in either the choice of particular agents or the administration of pharmaceutical benefits. The single BMHCO interviewed who is involved in managing pharmaceutical benefits performs utilization review and case management for its MCO, employer, or State customers. This company often serves as an administrative organization for their customers by the handling cost and utilization data necessary to project risk and justify rates. The BHMCO emphasized that available data are not adequate for analysis and stressed the need for better data collection.

• Special Populations

  • The New York State Corrections system did not report engaging in any formal DUR activities. The IHS performs DUR in-house, designed to assure quality, safety, formulary compliance, and cost minimization. Criteria included in regular reviews of drug classes include overuse, underuse, and avoidance of drug-drug interactions. These criteria do not differ from those used in other drug classes.