MassHealth Statewide Child Survey
In February 2010, Massachusetts was awarded a five-year federally funded Children’s Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration grant. The grant supports the development and maintenance of an integrated approach to measurement and quality improvement of pediatric health care delivery that will lead to transformational gains in children’s health outcomes. CHIPRA requires states to assess parent satisfaction with their children’s health care using the Agency for Healthcare Research and Quality’s (AHRQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey.
In collaboration with the MassHealth Quality Office, University of Massachusetts Medical School’s Office of Survey Research implemented a MassHealth statewide child survey to meet the objectives of the CHIPRA grant as well as the objectives of the Primary Care Clinician (PCC) Plan and the MassHealth Managed Care Organization (MCO) Program.
- A simple random sample of MassHealth members, ages 17 years or younger enrolled in the PCC Plan or one of the MCOs as of December 31, 2012, was drawn.
- The 63-question survey consisted of core items from the CAHPS 5.0H, supplemented by questions on specialized care.
- The survey was administered to the parents and guardians of 1,989 health plan members between April and July 2013 through a two-wave mail protocol with telephone follow-up for non-respondents.
- Written surveys were administered in English and Spanish, and both English and Spanish speaking interviewers were available for telephone respondents.
Overall, the survey had an adjusted response rate of 50.2%, excluding ineligible cases. Survey information was used to meet the CHIPRA core measure requirement and assist MassHealth in identifying opportunities for improvement in the delivery of care.
Pharmacy Intervention Reduces Improper Drug Combinations
Atypical antipsychotics — tranquilizing medications used to manage psychosis — account for about 12 percent of total prescription drug spending in the U.S. When prescribed incorrectly, they can raise health care costs unnecessarily.
Treating schizophrenia patients with more than one atypical antipsychotic can increase the risk of side effects or drug interactions. It also decreases the likelihood that patients will follow prescribing instructions accurately.
The American Psychiatric Association recommends prescribing one atypical antipsychotic medication for patients with schizophrenia, unless single-drug therapy fails multiple times.
Our client, a New England state Medicaid program, asked Commonwealth Medicine’sClinical Pharmacy Services team to determine whether a clinical intervention was needed to reduce the costs and risks of polypharmacy with this population.
Our pharmacy consultants collected and analyzed claims data and prescribing trends. The data showed the number of patients receiving antipsychotic therapy was inconsistent with current guidelines:
- Of 145,000 Medicaid members in the state, 480 were taking two or more atypical antipsychotic drugs.
- Patients transitioning to new medications needed no intervention.
- The 172 patients receiving two or more atypical antipsychotics for longer than 60 consecutive days required clinical intervention.
Our pharmacy staff sent providers a formal, patient-specific letter and encouraged them to initiate a doctor-patient conversation regarding appropriate treatment. All prescribers were asked for the following information:
- A close review of information provided
- Validation of clinical programs
- Assessment of need for clinical intervention
Our staff followed up with providers who did not respond. To assess the impact on therapy, we collected and analyzed claims data again six months after the intervention letters were mailed.
In the population originally identified as receiving two or more atypical antipsychotics for more than 60 consecutive days, 32 percent were no longer receiving polypharmacy therapy during the post-letter assessment period. The improvement in prescribing habits among the targeted prescribers resulted in an annualized cost savings of $120,000 for this state Medicaid agency.
Dose Consolidation Reduces Drug Cost
When patients are asked to take multiple daily doses of behavioral health medication, the cost of therapy increases — and so does the risk of negative medical outcomes due to complex dosing regimens. Still, many providers prescribe multiple daily doses for their patients, rather than a higher-strength tablet or capsule to be taken once-a-day. Identifying and educating these providers and patients can be challenging, making it difficult to capture the potential savings of a once-a-day dosing regimen.
Since behavioral health medications account for more than 13 percent of all Medicaid prescription claims, this state’s Medicaid program wanted to identify ways to cut spending on these drugs.
Commonwealth Medicine’s Clinical Pharmacy Services designed a program to combine dosage consolidation and quantity limitation protocols for the lower strengths of five frequently prescribed, brand-name behavioral health medications:
We converted multi-dose regimens to an equivalent dose — with a higher-strength tablet or capsule taken only once a day.
Our consulting team then evaluated patient utilization and cost outcomes under the new program, which is designed to improve patient adherence and reduce medication costs.
To determine the extent of the problem, Commonwealth Medicine’s clinical consultants looked at three months of data to identify potential dosage consolidation opportunities for Abilify, Zyprexa, Effexor-XR, Lexapro, and Zoloft. They found that 418 patients were taking lower-strength forms of these products multiple times per day — even though higher strength, single-dose forms of the same products were readily available.
Commonwealth Medicine’s team embarked on a prescriber education program and sent patient-specific, pharmacist-reviewed mailings to 250 physicians. Personalized letters provided specific information and included a Physician Response Form to track whether the physicians took action as a result of the dose consolidation initiative. Physicians also received a prior authorization request form to return if keeping the patient on the current dosage form and/or regimen was clinically justified.
By comparing pharmacy claims data from before and after the implementation of the Drug Utilization Review Board’s rule changes, our pharmacy team found that dose consolidation and quantity limitation initiatives decreased utilization and cost for the five behavioral health drugs.
- The Medicaid program saved more than $310,000 in a six-month period.
- 51 percent of physicians agreed to change their prescribing regimens to a higher strength of the medication to be administered once each day.
Commonwealth Medicine’s findings suggest that using the same methodology across other therapeutic areas, such as asthma, insomnia, and heart disease, would likely result in additional cost-savings and improved patient adherence.
Global Assistance Improves Laboratory Network for TB Testing in Peru
Accurate, timely drug susceptibility testing is essential for identifying drug-resistant tuberculosis (TB) and then establishing effective treatment regimens for patients. However, limited resources in nations such as Peru can make this high-complexity laboratory testing difficult to provide. As a result, more than 4,000 Peruvians die each year due to active TB.
Participating in a five-year Gates Foundation grant awarded to Harvard Medical School, the Massachusetts Supranational TB Reference Laboratory (MSRL) led the effort to increase Peru’s laboratory capacity for diagnosing TB, in collaboration with other grant partners.
The MSRL has been designated as part of an international network to standardize methods for diagnosing TB and its drug-resistant strains in high incidence locations. The laboratory is managed and operated by Commonwealth Medicine, UMass Medical School's health care consulting division.
To increase laboratory capacity and capability, the MSRL partnered with the Peruvian National Reference Laboratory to transfer technology and implement standardized operational procedures. We provided effective diagnostic tools, training for laboratory professionals, and enhanced laboratory infrastructure.
With the support of the MSRL, Peru’s national laboratory system has become a model for other nations with a high incidence of multidrug-resistant TB.
Our initiatives resulted in the following improvements:
- Shorter turnaround time to allow for earlier patient care
- Improved access to drug susceptibility testing
- Lower cost per test
- Increased capacity to meet the needs of Peru’s National Tuberculosis Control Program
- More highly trained staff with the ability to develop, validate, implement, troubleshoot, and manage high-complexity testing
- Cultivated laboratory safety
- Advanced sustainable quality assurance
- More accurate surveillance data on the prevalence of drug-resistant TB in Peru
Building a Quality Assessment Program for TB Laboratories in Haiti
Controlling tuberculosis (TB) through diagnosis, treatment, and monitoring requires a network of laboratories with accurate and reliable means of testing.
In Haiti, direct smear microscopy of respiratory specimens has been the main means for diagnosing TB. As a result, quality assessments of sputum smear microscopy are essential for evaluating technical proficiency.
The Laboratoire National de Santé Publique, a national public health laboratory in Haiti, was established in 2006 to serve as a national reference testing center. It provides direction and organization of quality assurance programs. In 2008, the network of microscopy centers consisted of 238 public and private centers, with only one private center providing culture and limited drug susceptibility testing.
With support from the Massachusetts Supranational TB Reference Laboratory (MSRL), the Laboratoire National has established an external quality assessment program using panel testing slides set as the first measurement of acid fast bacilli (AFB) microscopy performance in Haiti. Twenty high-volume smear microscopy centers were evaluated. The International Union Against Tuberculosis and Lung Disease (IUATLD) grading scale and scoring system were adapted for evaluation of panel testing results.
The MSRL, managed and operated by Commonwealth Medicine — the health care consulting division of UMass Medical School — has been designated as part of an international network to standardize methods for diagnosing TB and its drug-resistant strains in high incidence locations.
The initial set of 400 slides with varying AFB quantities was prepared at the MSRL. This set was comprised of five groups with various AFB loads.
Standardized panels containing five stained and five unstained slides with varying AFB quantities were validated by the MSRL and co-validated by the Laboratoire National Haiti.
The validated panels were distributed to a group of 20 high-volume microscopy centers. Results were assessed and scored. After pre-intervention measurement, on-site corrective action activities were formulated with the Laboratoire National. The Laboratoire National initiated refresher course training activities, reinforcing standardized techniques. Post-intervention performance was evaluated using a second panel, testing slide set with the same degree of challenge.
Pre-intervention measurement revealed a proficiency average of 60 percent. When the least stringent scoring criteria were applied, 18 laboratories (90 percent) performed below 80 percent. This early data demonstrated performance issues.
Post-intervention measurement revealed the following:
- Overall improvement of 27 percent
- Number of laboratories with performance below 80 percent decreased from 18 to four (20 percent)