Our Mission. How does Colorado Medicaid Work? Objectives

Transcription

1 How does Colorado Medicaid Work? Understanding the Delivery of Pharmaceutical Care Cathy Traugott, JD, RPh Client and Clinical Care Office Pharmacy Unit Manager Department of Health Care Policy and Financing Our Mission Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources Objectives 1. Recognize the process supporting development of the preferred drug list and prior authorization criteria and the prior authorization process 2. Understand recent or anticipated changes to drug classes covered by Medicaid 3. Understand departmental initiatives to improve quality and safety of care for patients related to pain management, prescription drug abuse, and opioid overuse 4. Identify opportunities to optimize drug therapy management through Medicaid Medication Therapy Management (MTM) and the Regional Care Collaborative Organizations (RCCOs) 1

2 CE Questions 1. What does the process for drug coverage on the PDL entail? A. Clinical review by P&T Committee and Department B. Stakeholder input C. Prior authorization criteria development with DUR Board input D. All of the above 2. What were the key findings in the DUR reports regarding opioids? A. 90.3% of prescriptions were for short-acting opioids B. Over 2,000 members were receiving in excess of 100 mg/day morphine dose equivalents C. 14.6% of members receiving opioids were less than 18 years of age D. All of the above 3. True or False: The Department pays for MTM-like services. CE Questions (continued) 4. True or False: The goal of the ACC is increased coordinated care. 5. What are the criteria for pharmacist participation in RX Review? A. There are no criteria. B. It just requires a Colorado pharmacist license. C. The pharmacist must have an unrestricted pharmacist license in Colorado, liability insurance, and meet certain educational requirements. Drug Coverage Policies Medicaid programs must cover all rebateable drugs for medically accepted indications Allowable restrictions Preferred Drug List Prior Authorizations Quantity Limits/ Age Restrictions provider-forms 2

3 Preferred Drug List (PDL) Department determines drug classes subject to PDL Drug classes are reviewed annually New drugs in an existing drug class on the PDL are generally added as a non-preferred drug PDL is published on the Department s website Preferred Drug List (PDL) The Pharmacy and Therapeutics (P&T) Committee Reviews a drug class for safety and efficacy 7 physicians, 4 pharmacists, 2 client representatives - independent of Department Prior to and during P&T meetings the Committee hears public testimony from stakeholders Committee submits recommendations to the Department Department determines preferred status of drugs Non-Preferred drugs are referred to Drug Utilization Review (DUR) Board for recommendations on prior authorization criteria Preferred Drug List (PDL) The Drug Utilization Review (DUR) Board Recommends criteria based on clinical information, public testimony and drug utilization review analysis 4 physicians, 4 pharmacists, 1 non-voting pharmaceutical industry representative - independent of Department Board makes recommendations to Department on clinical appropriateness and cost effectiveness Department evaluates recommendations in order to develop prior authorization criteria for PDL 3

4 Prior Authorizations Appendix P Drugs subject to prior authorization that are not included on the PDL are listed on Appendix P The DUR Board often makes recommendations on prior authorization criteria for these drugs as well Department makes final determination for prior authorization criteria Ex: Synagis, Short-Acting Opioids, Smoking Cessation Products Prior Authorization Process What happens after a claim is rejected at the pharmacy? Physician or an agent of the physician may call the PA Help Desk for a prior authorization ( ) or fax PA request form to some pharmacies may call as well Prescribers must sign all PA request forms PA escalation may be requested to be reviewed by a department clinical pharmacist System generated letter sent to member and prescriber as an approval or a denial Appeal of a denial may be sent to Office of Administrative Courts Recent and Anticipated Changes in Drug Classes 1. Growth Hormones 2. Opioids 3. Hepatitis C Virus 4. Cystic Fibrosis 5. Tobacco Cessation 4

5 Example - Hepatitis C Timeline of review of new drugs Criteria developed with input from DUR Board and community stakeholders PA Forms: %2003%2001%20Viekira%20Prior%20Authorization %20Form.pdf %2003%2001%20Sovaldi%20Harvoni%20Prior %20Authorization%20Form.pdf Pain Management Initiatives 1. Governor s Initiative 2. New short-acting opioid policy 3. Pain Management Resources on Department web page 4. Upcoming morphine equivalent policy 5. Chronic Pain Disease Management Program (Project ECHO) Governor s Initiative 1. Started as an initiative with National Governor s Association Governor Hickenlooper, co-chair of Policy Academy to Reduce Prescription Drug Abuse 2. Resulted in Colorado Plan to Reduce Prescription Drug Abuse - a coordinated, statewide strategy; simultaneously restricts access to Rx drugs for illicit use, while ensuring access for those who legitimately need them. 3. Colorado Consortium for Prescription Drug Abuse Prevention 4. Initiatives to improve quality and safety of care for patients related to pain management, prescription drug abuse, and opioid overuse 5

6 Medicaid Opioid History Quantity limits were placed on long-acting opioids Long-acting opioids were added to the Preferred Drug List No prior authorization criteria on short-acting opioids Drug Utilization Review Analysis The Department s DUR contractor, the University of Colorado s School of Pharmacy, completed 2 reports analyzing opioid use in Medicaid population First report analyzed prescribing and usage of shortacting and long-acting opioids DUR evaluation conducted at 3 levels of analysis: the prescription level, the patient level, and the provider level. Second report provided method to identify high utilizers and potential policy recommendations to the Department Drug Utilization Review Findings 90.3% of prescriptions were for short-acting opioids Over 2,000 members were receiving in excess of 100 mg/day morphine dose equivalents 14.6% of members receiving opioids were less than 18 years of age For those members receiving in excess of 100 mg/day morphine dose equivalents, 33.3%, 17.7%, 7.9%, and 4.2% were receiving 2, 3, 4 or 5+ opioids The majority of prescribers appear to be physicians 8.1% are family/pediatric nurse practitioners, 11.6% are physician assistants, 7.8% are dentists and 1% are podiatrists 6

7 Drug Utilization Review Findings (continued) DUR contractor evaluated risk of opioid overdose in highutilizers of opioid medications Analysis was limited to morphine equivalents, number of pharmacies used, and days supply to help identify possible criteria for the Department Based on these 3 variables, risk of overdose from opioids is over 10-fold for people who have morphine equivalent doses greater than 100mg, who use more than three pharmacies, and have more than 300 days supply of opiates. Short-Acting Opioid Policy On August 1, 2014, the Department implemented limits on short-acting opioids of a maximum of 4 tablets per day (equating to 120 tablets per 30 days) Exceptions can be made for terminal illnesses and sickle cell anemia Prescribers can request a 6-month override for members receiving more than 120 tablets per 30 days in order to have time to taper down to 4 tablets per day Other states have similar policies Short-Acting Opioid Policy On August 25, 2014, clarifications were made for acute pain Exceptions can be made for more than 4 tablets per day for acute pain This can be handled by the pharmacy and does not require prescriber intervention The total number of pills still cannot exceed 120 in 30 days 7

8 Pain Management Resources Provider Resources (billing and referrals) Pain Assessment Risk Assessment (abuse or misuse) Reporting/ Monitoring Opioid Use (PDMP) Tapering, Converting, Discontinuing Pain Guidelines Patient Education Non-pharmaceutical options Next Steps The Department will monitor impact of this policy Review the impact on short-acting and long-acting utilization Further review of members receiving the highest doses of opioids Further review of the prior authorization criteria for both shortacting and long-acting opioids The Department is working toward review of claims by morphine equivalents rather than per pill Chronic Pain Disease Management Program Modeled after the Project ECHO (Extension for Community Healthcare Outcomes) programs Two year initiative Cutting edge telehealth technologies connect PCMPs to specialists 8

9 Purpose Improve health of Medicaid clients with chronic pain and painrelated opioid dependence Address rising rates of prescription abuse Foster collaboration between PCPs and specialty care providers Promote adherence to evidence-based guidelines Support practice change to improve management of chronic pain Components 1. Chronic Pain Provider Collaborative 2. Buprenorphine Provider Collaborative 3. Practice Transformation Learning Collaborative Provider Collaboratives Modelled after Project ECHO Sessions led by multidisciplinary team of specialists Virtual clinics using easy-to-access videoconferencing tools Short didactic presentations Cases presented by participating PCPs for consultation Specialists provide recommendations and best practices that can be implemented within PCP office 9

10 Provider Collaboratives 1. Chronic Pain Provider Collaborative Designed for CO Medicaid providers Reinforce CO policies (e.g. Quad Policy) 2. Buprenorphine Provider Collaborative Designed for licensed providers Feature specialists in addiction and substance use disorders Provider Collaboratives Year-long with Bi-monthly sessions minute didactic 90-minutes of case presentations Website Benefits: Available to all practice providers, not just attendees. Recordings from all ECHO sessions, searchable by topic Chat function allows sharing of resources, knowledge and professional services during session Provider Collaboratives Multidisciplinary teams of specialists to include: Behavioral health specialist Pharmacist Pain management specialist 10

11 Practice Transformation Learning Collaborative Assist practices with: Identifying systems-level gaps Developing action plans Adherence to evidence-based guidelines Drug Therapy Management The Department recognizes benefits of MTM MTM needs to be coordinated with other Department initiatives to be effective This includes the Accountable Care Collaborative (ACC) and the corresponding Regional Care Collaborative Organizations (RCCOs) ACC Approach Not traditional managed care Offers full benefits of Medicaid Connects members to medical and non-medical (social) services to support health Coordinated care at regional level 11

12 Strategies Every member has a Primary Care Medical Provider (PCMP) All ACC members and PCMPs belong to a local Regional Care Collaborative Organization (RCCO) Unprecedented access to data from the Statewide Data and Analytics Contractor (SDAC) Gradual introduction of payment strategies to reward outcomes instead of volume The Accountable Care Collaborative Regional Care Collaborative Organizations (RCCOs) Primary Care Medical Providers (PCMPs) Statewide Data and Analytics Contractor (SDAC) RCCO Map Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Rocky Mountain Health Plans Colorado Access Colorado Access Integrated Community Health Partners Colorado Access Colorado Community Health Alliance Community Care of Central Colorado 12

13 RCCO Role Achieve financial and health outcomes Ensure a Medical Home level of care for every Member Network Development/Management Provider Support Medical Management and Care Coordination Accountability/Reporting PCMP serves as a Medical Home Member/family centered Whole person oriented Coordinated Promotes client selfmanagement Care provided in a culturally sensitive and linguistically sensitive manner Accessible PCMP Role SDAC Role Data Repository Data Analytics & Reporting Web Portal & Access Accountability & Continuous Improvement 39 13

14 Patient Data Available to PCMPs Value of the ACC Net savings of about $30 million Clients > 6 months in the ACC ER visits decreased for adults (21%) and children (2%) High cost imaging services were significantly lower for adults (35%) and children (19%) 30-day, all cause hospital readmissions were 33% lower for both adults and children Value of the ACC ACC clients, since 2012: Children with disabilities: 6% h in the number of professional care visits 7% i in ER visits Children with asthma 16% i in the number of preventable services Adults with disabilities 29% i in 30-day, all cause hospital readmissions Adults with diabetes 7% h in the number of professional visits 14

15 Prescription Drug Consumer Information & Technical Assistance Program Rx Review MTM light not formally approved as an MTM program Created through state legislation HB , C.R.S Client participation in program is voluntary Program is designed for high utilizers Receiving 5 or more medications per month For 3 months Totaling $2,000 or more in expenditures in each month Rx Review - How it Works Dept contracts with pharmacists who want to participate Contracted Pharmacists must meet qualifications set forth by the Colorado Board of Pharmacy. Contracted pharmacists complete medication reviews in person/by phone for targeted clients including: Screening for drug-drug and drug-otc/supplement interactions Screening for duplicative drug therapy Evaluating client's response to current therapy, including drug effectiveness and safety Correcting patterns of clients using multiple prescribers and/or pharmacies Department receives pharmacist s recommendation letter Payment: $75 face-to-face; $50 phone consultation 44 Rx Review - The Goals Achieve drug therapy treatment goals; Minimize undesirable medication effects; Improve client medication adherence; Enhance medication safety; and Reduce health expenditures

16 Drug Therapy Management and RCCOs Rx Review and RCCOs - independent programs Department encouraged and facilitated meetings between the RCCOs and pharmacy stakeholders for coordinated MTM and ACC efforts MTM services must be coordinated with other care coordination efforts in order to be effective Encourage continued discussions as the RCCOs evolve CE Questions 1. What does the process for drug coverage on the PDL entail? A. Clinical review by P&T Committee and Department B. Stakeholder input C. Prior authorization criteria development with DUR Board input D. All of the above 2. What were the key findings in the DUR reports regarding opioids? A. 90.3% of prescriptions were for short-acting opioids B. Over 2,000 members were receiving in excess of 100 mg/day morphine dose equivalents C. 14.6% of members receiving opioids were less than 18 years of age D. All of the above 3. True or False: The Department pays for MTM-like services. CE Questions (continued) 4. True or False: The goal of the ACC is increased coordinated care. 5. What are the criteria for pharmacist participation in RX Review? A. There are no criteria. B. It just requires a Colorado pharmacist license. C. The pharmacist must have an unrestricted pharmacist license in Colorado, liability insurance, and meet certain educational requirements. 16

17 Thank You Cathy Traugott, JD, RPh Client and Clinical Care Office Pharmacy Unit Manager Department of Health Care Policy & Financing 17