Provider compliance is a greater priority within the private sector than the public sector. This trend is consistent with the trend toward greater use of restrictive formularies and treatment guidelines in the private sector. Provider compliance programs are likely to grow in the future as the private sector insurers become increasingly concerned with cost-effectiveness.
The APA tracks prescribing practices of a sample of psychiatrists through the Practice Research Network (PRN). This program monitors issues such as the use of different classes of medications. The APA also attempts to monitor dosing practices, although these data have not been published. The primary goal of the PRN is to follow current practices in the treatment of mental illnesses and provide a platform for education to improve the quality of treatment provided by clinicians.
Local chapters of NAMI have engaged in educating provider groups and associations about clinical practice guidelines, such as those published by the APA. As in the case of the PRN, a primary goal of these initiatives is provider education in an attempt to improve care quality.
- Public Programs
Provider compliance programs generally do not operate in traditional Medicaid programs. Most drugs are available on formulary and few treatment guidelines are employed. Any willing provider (AWP) legislation generally excludes the possibility of provider credentialling. Medicaid Managed Care programs may monitor physicians for compliance, but this was not within the scope of our research.
State Mental Health programs do not monitor their providers for compliance with treatment or prescribing guidelines on a statewide basis. These programs often are implemented at the level of the individual hospital or community mental health center. As may be expected, such programs vary in scope between individual sites. The outstanding example is the TMAP (Texas Medicaid Algorithm Project). In Phase II of this program, a feasibility trial, physicians self-reported their use of the algorithms and preliminary results indicated the majority complied with the guidelines and would continue to use them after completion of the trial.34,35 Physician manuals are available at the Texas Department of Mental Health and Mental Retardation. The program does not plan to monitor providers for compliance with algorithms. However, some pharmaceutical prescribing patterns are monitored (e.g., different dosages accepted for different indications). Data collected in monitoring physicians is reviewed and physicians are contacted to confirm unique circumstances (via letters, etc.).
The DoD and the VA are more aggressive in monitoring provider practice patterns. Both routinely review provider records to monitor for compliance with formularies, evaluate dosing patterns, and monitor inappropriate use of medications. These evaluations are generally carried out at the local (i.e., treatment facility) level. The VA also carries out an external peer review of physician treatment practices.
- Private Payers
Within the private sector, strategies to monitor and encourage compliance with formularies and treatment guidelines include DUR, physician profiling, self-reported surveys and peer review. Physician profiling is perhaps the most aggressive of these methods, as individual physicians are provided with counts of their prescribing of individual drugs on a regular basis. Although most payers interviewed use formularies, treatment guidelines, and profiling primarily as educational tools, several do enforce compliance. Physicians who are found to prescribe off formulary frequently may be targeted by the payer for either education or encouragement to comply with the formulary. Both incentives (e.g., rebates) and disincentives (e.g., withholding of physician bonuses) are used to encourage provider compliance, although these practices appear to be less common than many may fear.
Manufacturers track provider treatment patterns in two ways. First, manufacturers monitor physicians who are high prescribers either of a particular medication or a general class of medications. Prescription data are available for purchase from several sources including IMS Health and Scott-Levin. These data form the basis for a manufacturer's detailing strategy by identifying physicians who are likely to prescribe a particular product or who may be candidates to target for switching. Furthermore, manufacturers target the broader payer population, offering rebates or contracts to health plans to encourage use of a particular product. Second, manufacturers may encourage physician compliance on the individual level by offering physician education programs or materials. One manufacturer also reported offering incentives to physicians who increase patient compliance and reintegration rates.
Most MCOs do not monitor providers for compliance with treatment guidelines or algorithms. However, many plans are beginning to implement comprehensive disease management programs that include a provider component.
One HMO interviewed reported instituting an early detection pilot study for depression within one of its medical groups. This program was developed internally and its organization and outcomes have not been published. This HMO reported that the goal of this pilot program was to develop a screening tool that included depression assessment and treatment guidelines for use by primary care physicians. The goal of this program was to screen patients for undetected or undiagnosed depression. The study team developed a simple, easy-to-use screening form and worked closely with the medical director and providers to improve it over the course of the study. The study team also offered training to providers on use of the assessment tool and treatment strategies. The HMO believes that the program has been successful in a variety of ways. First, this program achieved detection rates that approach what the Agency for Health Care Policy and Research reports as the actual prevalence of depression. Further, most of these patients are willing to pursue treatment. Lastly, physicians are complying with the study, even though the bonuses paid to physicians for performing the detection screen have run out.
Similarly, another integrated MCO is operating a pilot project to systematize the treatment of depression within primary care. The program specifically aims to demonstrate that primary care clinics can develop systems that consistently manage and follow-up depressed patients and to describe and evaluate the change process used to do this, the new care process and its effects. The project has found that regular low-end management (such as 4-5 minute telephone calls with patients) can have as much of an impact as medication on patients with depression.
Finally, another large group model HMO has developed a more comprehensive disease management program for depression. The program consists of disease management guidelines for use in both primary care and specialty behavioral health settings. The guidelines give recommendations for appropriate dosing of medications, and specify that either TCAs or SSRIs are acceptable first-line choices of medication for depression. The choice of a particular agent is left to the physician who is expected to consider cost in making a choice of agent. The program collects data on patients enrolled in the program, including measures of illness severity, medication regimen, costs and treatment outcomes. Within the first year of operation, this program successfully enrolled 50% of new depression patients.
PBMs generally do not enforce physician compliance with treatment guidelines or disease management programs, but encourage compliance through education and notification. One PBM asks physicians to complete a volunteer survey. Another runs a quality initiative based upon SSRI compliance. Maintaining patient confidentiality often precludes adequate data collection and monitoring on a case specific basis.
Employers monitor providers for compliance with guidelines via concurrent or retrospective DUR. This process is usually contracted out to a PBM or other outside source. Furthermore, employers may partner with their PBMs or HMOs to conduct provider education. Employers who take a more activist role in the management of their health benefits report that they are attempting to implement programs to monitor providers for quality assurance purposes.
- Special Populations
In the correctional system, providers are internally monitored for compliance with treatment algorithms and guidelines through the health information management department. The management department generates pharmacy profiles of physicians and patients which provides a vehicle for "auditing" provider compliance.
The Indian Health Service does not monitor providers for adherence to treatment guidelines on a regional or national level. Individual treatment facilities develop their own protocols and clinicians are monitored for compliance at that facility.