1. A Big Unknown : How to Use Data to Improve Policy and Quality Jeffery Thompson, M.D. Chief Medical Officer Washington State Medicaid Academy Health Washington DC June 8 th 2008

2. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 2 Today’s agenda: 1. Discuss local and national variations in Medicaid programs and Secular Trends – How to Measure the Un-measurable 2. Discuss the need to go beyond claims data – there is a treasure chest of data but where is the map 3. Show a picture of what happens when data and policy work together – Things Happen

3. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 3 Washington State: FFS & managed care When you seen one Medicaid State – You seen one Medicaid State! BS Truth: Medicaid States have similar populations and similar service trends that in many ways are the same as commercial markets

4. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 4 Input and Outputs of Mental Health Issues: Secular Events in and out of Medicaid are tough to study or even know!  Utilization controls  Cost Saving policies, code and statutes  Continuity of Care  Adherence to therapies  Regional variations  High Risk Eligibility types  (foster care, homeless, chronic health issues)  (foster care, homeless, chronic health issues)  Diagnosis accuracy  Dosing and safety thresholds  Dosing and safety thresholds  Drug and Alcohol  Criminal Justice  Criminal Justice Missing a secular trend often generates type 1 or 2 error. Researchers must have closer working relations with policy and staff

5. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 5 CONCLUSIONS: High expenditures on these medications are thus likely to continue without concomitant gains for public health. The value of “on label ” and “off label” is in the eyes of the reader or disbeliever. The 900 page tech assessment is not enough!

6. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 6 Anti-Psychotic drug expenditures Washington State, 2000 - 2007 The AAP class is the No. 1 expenditure for most Medicaid states. The 21% growth in AAP costs is driven by both unit cost and growth in utilization: This gets the attention of administrators

7. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 7 Regional variation in Washington: Large differences between counties Map shows excessive AAP dosing (*) in CY 2007 among children (under 18 years old) Regional variation in Washington: Large differences between counties Map shows excessive AAP dosing (*) in CY 2007 among children (under 18 years old) Showing provider and regional variation: This gets the attention of providers

8. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 8 Mental Health Care Variation in Washington : Large differences between counties re- hospitalizations compared to Gap in AAP therapy by Mental Health Contractors * NOTE: 9000 Clients with schizophrenia: Relationships holds for poly-pharmacy (#Rx/year) and Poly-prescriber (#Rxers/year) ER utilization and SNF care rates Looking at data across systems is more informative than by systems: The data generated a review of 2500 high costs clients and 40 record reviews

9. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 9 Linking Deaths and Smokestacks Washington State, 2004 – 6 (narcotic related deaths in Medicaid – linking 357 death certificates to claims data) Integrating across agencies and data systems is a must because Contracts and payment systems do not treat the riskiest clients. This data has sold a narcotic review program and provider support WA Medicaid is 42% of all narcotic related deaths

10. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 10 DOSE, AGE and COMBIATION STOPS in ADHD Therapies: A Community Agreed Prescribing Program (WAPA, AAFP, WASPA, P&T/DUR) Age – Less than 5 years old Dose – Amphetamines 60mg, Methylphenidates 120mg COMBINATIONS - o Combinations of Strattera with stimulant ADHD drugs require Prior Authorization; tapers are authorized for a maximum of 30 days. Strattera Threshold for 5 years and older – 120 mg per day as a single daily dose. –Allow mono-therapies with 8 weeks Cross over –Combination therapies require Tried and failed mono-therapies What Sells: Showing the # of 1 year olds and kids on > 3 stimulants works when EBM is not enough

11. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 11 Learning and Implementing other state processes: Learning and Implementing other state processes: ADHD second opinions for stimulant prescriptions (2004-2008) There are ~27,000 users of stimulants with 1000 ADHD Second Opinions that resulted in: Rxs for Children less then 5 year old 24% Poly pharmacy use 48% High doses of stimulants 63% Most stimulants in utilization (-0.4 to -35%) There are NO less than 5 year olds on high dose stimulants What about the other outcomes (Juvenile Justice, truancy, foster care placements, graduation rates, ER etc)? We need to go beyond claims data

12. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 12 Multiple state processes Which process is a “best practice” and which combinations offer the best outcomes of access, quality, safety and cost? We need more cross-state comparisons! Second opinions Tennessee, Washington Preferred drug lists Illinois, Florida Phone-based West Virginia, Texas Consultations Mississippi, Washington Lilly CNS program Florida, Rhode Island, Oregon Step therapies, guidelines Texas Prior authorization Ohio

13. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 13 We need the policy bottom line!!!!!!!!! can be managed with policy Clinical algorithms that are communicated with Provider specific report cards reduce variation Preferred drug lists can be used without decreasing clinical quality Second opinion programs can improve safety and reduce clinical variation Refill protections, grandfathering and dispense as written protections are good policies There is evidence that policy programs can support and improve the clinical value of state funded AAPs in Kids: The Lilly CNS program reduces safety related issues In AAP prescribing

14. Using Data to Improve Policy and Quality Academy Health Washington, D.C. June 8, 2008 14 Questions?