Although newer antidepressant and antipsychotic medications were much more readily available to health care consumers in 1999 than they were when first introduced, health care payers have been less aggressive at promoting appropriate use than they had been at discouraging inappropriate use. Primary research indicated few cases where payers have implemented processes and procedures to insure appropriate prescribing and dosing, detection of mental illness, reimbursement, or patient compliance with care. These programs appear to be in their infancy, with many respondents indicating that their programs were relatively new. In this section, we report on the status of utilization as assessed in our research.
In summary, this study found:
Health care payers have not been active in designing treatment algorithms or comparing the effectiveness of competing agents head to head.
- The treatment algorithms that do exist largely give general guidance to the clinician and leave choice of individual agents and precise dosage to the clinician.
- Treatment algorithms are more common in closed systems such as group model HMOs and payers such as DoD or the VA.
- The paucity of specific guidance reflects the lack of consensus as to which of the newer agents is superior and for whom.
Clinical development and marketing decisions affect the utilization of any pharmaceutical agent. However the impact of marketing strategies on utilization has not been assessed in any systematic way.
Most payers use some form of utilization review mechanism to track the utilization of psychotherapeutics.
- These programs are applied to any drug class that may represent a large proportion of spending.
- The goal of these programs is to track duplication, overuse, underuse, and possible drug interactions.
Payers are more likely to monitor providers for compliance with formularies or protocols than they are to monitor consumers for compliance with therapy.
A. Treatment Guidelines and Preferred Medications
Guidelines for the treatment of schizophrenia, depression and other mental disorders have been produced by various sources. By and large, however, these have been the products of individual health plans, health service programs, or professional associations. Two sets of guidelines have come from national sources: The Agency for Health Care Policy and Research (AHCPR) has published guidelines for the treatment of depression in primary care30 as well as the findings of the Patient Outcomes Research Team (PORT) study on the treatment of Schizophrenia.31 The American Psychiatric Association produces clinical practice guidelines for a variety of mental illnesses including Major Depressive Disorder32 and Schizophrenia.33 In general, all guidelines list effectiveness, safety, patient history, and cost as important factors to consider in making treatment decisions.
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.
Programs that monitor patients for compliance with therapy, or providers for compliance with treatment guidelines, are in their infancy. Provider compliance programs usually take the form of monitoring for adherence to a formulary, although programs that monitor for compliance with treatment guidelines are growing in popularity. It should be remembered, however, that treatment guidelines usually take the form of recommendations on overall pathways of care (usually including the use of pharmaceuticals), rather than rigid guidelines on drug choice and dosing recommendations. Therefore, monitoring physicians for the appropriate use of psychotherapeutics is yet to be widely used.
Payers have been slow to implement patient compliance programs, largely because requirements for maintaining patient confidentiality make tracking mental health patients difficult at best. Nevertheless, some employers and managed care plans have begun to implement such programs in the form of call centers or educational programs (e.g., pamphlets). Disease management programs are intended to foster patient compliance; however, pharmaceutical compliance is only one aspect of these programs. PBMs take the most active role in encouraging patient compliance with pharmacotherapy by using various forms of reminders to patients to refill prescriptions.