Quarterly, state level data on prescription drug utilization are available from the Health Care Financing Administration(now known as Centers for Medicare and Medicaid Services(CMS)) (HCFA(now known as CMS)). These data are reported at the National Drug Code (NDC) level. These data include all pharmaceuticals reimbursed through State Medicaid phar
Access and Utilization of New Antidepressant and Antipsychotic Medications. Chapter VI. Patterns of Antipsychotic and Antidepressant Utilization in Medicaid, 1995-1998
The truest measure of access to and utilization of pharmaceuticals is analysis of actual patterns of claims processed for individual drugs. Although analysis of these patterns across all health care payers is outside the scope of this research, this section analyzes trends in utilization of antidepressants and antipsychotics in Medicaid between 19
Access and Utilization of New Antidepressant and Antipsychotic Medications. Patient Compliance/Disease Management
Patient compliance and disease management programs appear to be more common in the private sector than the public sector. This observation likely reflects several trends currently operating in the mental health services sector. These trends include:
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
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 remem
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 di
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 ofte
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.
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 managem
Manufacturers devote considerable effort to marketing psychotherapeutics to physicians, although tactics vary. For example, both Janssen and Eli Lilly maintain a specialized detail force for mental health, whereas SmithKline Beecham promotes paroxetine largely through a non-specialty force. AstraZeneca promotes quetiapine through a generalized sal
Access and Utilization of New Antidepressant and Antipsychotic Medications. Clinical Development and Trial Design
The clinical trials submitted for review to the FDA by the manufacturer determine the indications for which a drug may be marketed. Although trials used to obtain approval may be sufficient to convince regulatory authorities that a new drug is safe and effective, their design may or may not be adequate to convince health care payers that a new dru
Access and Utilization of New Antidepressant and Antipsychotic Medications. Special Population Guidelines
The New York State department of Corrections currently administers treatment algorithms and guidelines for the treatment of mental illness. The primary goals of these programs are to provide the highest level of care combined with some level choice to individuals with mental illness.
Access and Utilization of New Antidepressant and Antipsychotic Medications. Private Sector Guidelines
Several health care payers and health maintenance organizations have produced more explicit guidelines for the choice of antidepressant and antipsychotic medications. These range in scope from designations of preferred medications to more comprehensive sets of guidelines for the management of these illnesses.
Access and Utilization of New Antidepressant and Antipsychotic Medications. Public Program Guidelines
The Health Care Financing Administration(now known as Centers for Medicare and Medicaid Services(CMS)) does not in general instruct States on the choice of individual pharmaceutical agents for inclusion in formulary or treatment guidelines. However, HCFA(now known as CMS) has sent a letter to State Medicaid Directors urging the coverage of atypica
The AHCPR depression guidelines, published in 1993, describe a range of issues to be considered in the selection of a pharmacological therapy for depression. These guidelines specify that one of the SSRIs available at the time of publication (fluoxetine, sertraline, and paroxetine), bupropion, trazadone, or a secondary amine TCA (e.g., notriptylin
Access and Utilization of New Antidepressant and Antipsychotic Medications. 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.
Access and Utilization of New Antidepressant and Antipsychotic Medications. Chapter V. The Current State of Antidepressant and Antipsychotic Utilization
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 im
A principal finding of this study is the absence of traditional step care protocols, whereby patients are required to try an older generation agent prior to obtaining approval for reimbursement of a newer one. This situation represents a shift from the situation several years ago, where trial of either a tricyclic antidepressant or a typical antip
Prior authorization does not generally operate in the New York State corrections system. Off-formulary drugs are theoretically available in the IHS via prior authorization. Any physician can make a PA request. The staff pharmacists and clinical directors at the central area office review these requests. A decision is returned in three working days