The Pediatric Behavioral Health Medication Initiative (PBHMI), a program developed by UMass Medical School and MassHealth, Massachusetts’ Medicaid program, may help reduce the use of pediatric behavioral medications, according to an article in Managed Healthcare Executive Oct. 29.
Two pharmacists within UMass Medical School’s Commonwealth Medicine division discussed the program during the Academy of Managed Care Pharmacy Nexus 2015 conference Oct. 28. Kimberly Lenz, PharmD, clinical pharmacy manager for the Office of Clinical Affairs and an assistant professor of UMass Medical School’s Family Medicine and Community Health, and Donna M. Faber, PharmD, BCPS, a clinical consultant pharmacist in Clinical Pharmacy Services, said in the article that the program established guidelines for behavioral health medications and polypharmacy, and requires prior authorizations under certain guidelines.
The program, initiated in two phases, was developed after the U.S. Government Accountability Office found Massachusetts had the highest rate of behavioral health medication use compared to other states, and that the medications were usually prescribed for foster children and those who have Medicaid coverage, the article said.
“We had to create a robust guideline … it is all evidence based,” the article quotes Lenz, who added that the guidelines comprise more than 100 pages. “You really have to address all of the different types of situations you’re going to see.”
The guidelines described in the article include: prior authorization requirements for MassHealth members younger than age 3 for any pharmacy claim for alpha2 agonist or cerebral stimulant; prior authorization requirements for members younger than age 6 for any pharmacy claim for an antipsychotic, antidepressant, atomoxetine, benzodiazepine, buspirone, hypnotic or mood stabilizer; and prior authorizations for members younger than 18 for pharmacy claims for certain behavioral health medication combinations.
The first phase, which concerns age restrictions for behavioral health medications, was implemented in November 2014, and the second phase, on polypharmacy restrictions, began in February 2015, according to the article.
Planning for the implementation of the program included analyzing pharmacy claims and identifying prescribers, then reaching out to prescribers through emails and phone calls and emphasizing the initiative was aimed at safety, not cost-cutting, according to the article.
“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,” Faber is quoted in the article.
Since the program began in November 2014, the article said there have been 14,867 prior authorizations, with 10,380 approvals, 4,301 provisional approvals and 186 denials.
Lenz said in the article that it is critical for health plans considering a similar model to be aware that it is a small piece of a large puzzle.
“As soon as you touch that one piece the whole puzzle kind of just goes crazy and changes the dynamic of things,” Lenz 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.”