Prior approval program stems surge of psych med scripts for at-risk kids

The increasing use of behavioral health medications and polypharmacy, especially in the pediatric population, is concerning. But a new Massachusetts program may help address this issue.

The program, known as the Pediatric Behavioral Health Medication Initiative (PBHMI), was developed by the MassHealth Pharmacy Program after the U.S. Government Accountability Office (GAO) reported concerns with behavioral health medications prescribed in children in Florida, Massachusetts, Michigan, Oregon, and Texas

A December 2011 GAO report found that Massachusetts had the highest rate of behavioral health medication utilization compared to other states, and that behavioral health medications were more likely to be prescribed to foster care children. That report was followed by a December 2012 GAO report that found that behavioral health regimens with more than medications were more prevalent in foster care children, and that antipsychotic use in children covered by Medicaid was twice as likely compared to those with private insurance.

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But behavioral health medication and polypharmacy problems associated with pediatric patients are not just confined to Massachusetts. According to numerous reports, behavioral health medication use has increased among children, behavioral health medication polypharmacy regimens have increased among children, and antipsychotic use in children and in combination with other behavioral health medications has increased.

During their session at the Academy of Managed Care Pharmacy Nexus 2015 in Orlando, Kimberly Lenz, PharmD, clinical pharmacy manager for the Office of Clinical Affairs at the University of Massachusetts Medical School Commonwealth, and Donna M. Faber, PharmD, BCPS, clinical consultant pharmacist for Clinical Pharmacy Services at the University of Massachusetts Medical School, shared more about the Massachusetts PBHMI, how it works, the outcomes, and the lessons learned. 

Key aspects of the program

The PBHMI program applies to members covered by MassHealth, which is the state's combined Medicaid and State Children's Health Insurance Program. It was initiated in two phases, the first phase, related to age restrictions in behavioral health medications, began in November 2014. The second phase, related to polypharmacy restrictions, occurred in February 2015, said Lenz.

The program established guidelines for behavioral health medications and polypharmacy, and it requires prospective prior authorization if those guidelines aren't met.

"We had to create a very robust guideline ... it is all evidence based," said Lenz, noting that the guidelines are more than 100 pages in length. "You really have to address all of the different types of situations you're going to see."   

NEXT: Program guidelines and preparation

Program guidelines

The guidelines were developed based on evidence-based guidelines with input from stakeholders such as the Department of Children and Families, the Department of Mental Health, and a Therapeutic Class Management Workgroup made up of a multidisciplinary team of  child/adolescent psychiatrists, pharmacists, and social workers, prescribers, said Lenz and Faber.

The guidelines include:

• Prior authorization (PA) requirements for members younger than age 3: Any pharmacy claim for an alpha2 agonist or cerebral stimulant.

• PA requirements for members younger than aged 6 years: Any pharmacy claim for an antipsychotic, antidepressant, atomoxetine, benzodiazepine, buspirone, hypnotic, or mood stabilizer.

• PA requirements for members younger than aged 18 years (eight restrictions related to polypharmacy): Pharmacy claims for certain behavioral health medication combinations. More information on the specific medications, number of medications, and duration included in this restriction, is available here.

Preparing for implementation

While the first phase of the program began in November 2014, planning for the implementation and guidelines started long before that, in January 2013.

"Before we were able to implement ... we had to determine how many members would be affected if initiatives like this one would be put into place," said Faber. The planning included retrospective pharmacy claims analyses and identifying prescribers prescribing medication to relevant members.

The planning process also included sending informational letters to the 14,000 prescribers of medication to MassHealth members under aged 18 years. It also included phone calls to 79 prescribers identified in the review as having five or more members that fell into the under aged 6 years restriction category, or having any members that fell into the under aged 3 category. Providers identified as having members that fell into the polypharmacy restriction category (239 providers) also received calls.

During this outreach, it was critical to emphasize to providers that the program was a safety initiative, not a cost-saving initiative, said Faber.

NEXT: Program outcomes and challenges

Program outcomes

The presenters shared nine months of data accumulated since the initiative began in November 2014. Overall, 14,867 prior authorizations have taken place due to the program, though Faber stressed that one member may have multiple prior authorizations. 

These prior authorizations resulted in 10,380 approvals, 4,301 provisional approvals, and 186 denials. If a provisional approval or denial occurs, PBHMI staff conducts prescriber outreach, said Faber.

Lessons learned

For plans considering embarking on such a model, it's critical to remember that this is a small piece of a big, complex puzzle, said Lenz. "As soon as you touch that one piece the whole puzzle kind of just goes crazy and changes the dynamic of things," she said. "...It's important that you make sure you have the right people at the table so that when you start taking apart that puzzle you can put it back together."

She said it's also important to use analytics and reports to continually monitor the program effectiveness, outcomes, and identify areas for quality improvement.

Finally, she said it's critical to have the manpower and capabilities to manage a significant influx of prior authorizations due to the new guidelines. "You really have to set up a very strong infrastructure," she said.