Disease Mangement

Some Depression DM Programs Build Rx Capabilities to Boost Compliance, Outcomes

Reprinted from the September 2, 2005, issue of INSIDE DISEASE MANAGEMENT.

Depression disease management programs have a strong pharmaceutical element, since medication therapy and talk therapy are believed to be the two most effective ways of treating the condition. To improve their medical management capabilities, some depression DM firms are making new internal investments or forming external partnerships to access pharmacy claims data, perform analyses of prescriber patterns and identify opportunities to improve appropriate utilization.

Many depression DM programs already use a wide range of medication management strategies, such as efforts to improve compliance and prevent side effects. Depression management typically starts with patient identification via claims review and referrals. The DM firm reviews all the medications used by the patient, including both psychotropic medications and those intended to treat comorbid or co-occurring conditions, in an effort to ensure that medications are being used appropriately and successfully. Interventions vary from Internet- and mail-based education materials to one-on-one physician and patient consultations.

Some depression DM firms, including Magellan Health Services, Inc. and Health Integrated, Inc., rely on patients' self-reported data to monitor ongoing compliance with medication regimens. Both firms say that programs under development could improve their ability to monitor changes in pharmacy utilization and prescriber practices.

Magellan is "bringing to market a new product that is a pharmacy analysis program," says Karen Smith-Hagman, chief of clinical and operations for Magellan's condition care management programs. The behavioral health company is partnering with some large health plan clients to obtain baseline data. "That program will include analysis of prescriber practices, and identify opportunities in prescriber patterns including their use and choice [of medications]," she says.

Smith-Hagman declines to provide more details, since the program is under development. But, she adds, Magellan already has identified a pharmacy partner.

Health Integrated would like to use pharmacy claims data to perform medication compliance checks, for example, says Sam Toney, M.D., vice chairman and chief medical officer. "We currently don't have the tie-in with PBMs [i.e., pharmacy benefit managers] that we would like.…It's really an issue with coordinating data with the client." But the firm is exploring ways to improve data change with clients in order to broaden its DM services, he says. "In fact, we are in discussion with a potential strategic-alliance partner that would help us to get a lot of that data from client to client," Toney says. He declines to furnish more details, explaining that "we're not quite there yet."

Both Magellan and Health Integrated say they already have robust programs aimed at improving medication compliance. Smith-Hagman says that the issue may be not that the patient does not want to take the medication, but rather that psychosocial or socioeconomic hurdles make it difficult to do so. "Sometimes it's as simple as finding a pharmacist to deliver medications," she says.

Health Integrated attempts to identify the causes of noncompliance, such as side effects, poor psychosocial support or provider issues, Toney says. The firm responds with patient education materials intended to improve compliance. "In addition, care managers utilize behavior-change techniques like motivational interviews" and provide feedback to patients on their health status in an effort to encourage them to continue on medication, he says.

Generic Promotion Strategies Vary

Given the emphasis on pharmaceutical management of depression, there is some potential to reduce costs associated with treatment by promoting generic versions of popular antidepressants. Generic versions are available for several drugs, including GlaxoSmith-Kline's Paxil, Pfizer Inc.'s Zoloft and Eli Lilly and Co.'s Prozac.

Some depression DM programs steer clear of generic promotion programs aimed at moving patients from brand-name to generic medications, however.

"We have encountered plans that have been concerned with the escalating cost of antidepressants," Toney says, but "we do not promote any particular agents." He explains that "it's not consistent with the core charter of the program, which is not to direct care, but rather to coordinate care."

The firm does provide limited reviews of prescribing patterns, though. "While we're not in the business of promoting generic step therapy or any various formulations," Toney says, Health Integrated does review care to identify suboptimal treatment, such as an inappropriate dosage, and intervene where necessary. The firm also has used its treatment criteria to perform some drug evaluation reviews and drug utilization reviews for clients. "We've only done a little of that to date," he adds.

Health Integrated has 4,000 depression patients under management. The firm's clients primarily are health plans, though it increasingly is pursuing employer groups and government payers, Toney says.

Magellan promotes generics in situations where a generic alternative will improve utilization, Smith-Hagman says. "For members who have a compliance issue because of the copay on a brand-name prescription and who have access to a generic that would decrease that issue and increase compliance, that would become part of the DM strategy," she says. In those situations, Magellan's care coaches "would encourage the patient to discuss with their prescriber whether there is a generic substitute." But, she adds, "it is not a primary role or a primary focus. We are trying to make sure members have the best clinical outcome, not just for the episode but improving the overall quality of life."

Because Caremark, Inc. is a PBM, its depression DM program — part of the CarePatterns suite of DM programs — has a strong pharmacy focus. But the program emphasizes the physician's role as primary patient care manager, says Michele Dodds, Psy.D., director of program development for CarePatterns. "We wouldn't suggest that they switch [medications]," she says. "First and foremost, we do actually defer to the physician in terms of overall management.

The CarePatterns depression DM program, launched in August 2005, focuses exclusively on patients who have just started two classes of antidepressants: selective norepinephrine reuptake inhibitors (SNRIs) and selective serotonin reuptake inhibitors (SSRIs). The program's two goals are to improve medication compliance and to encourage the dual use of talk therapy and medication therapy.

Still, Dodds says, "we primarily are a 'generics-first' company when available. All of our systems and all of our programs encourage" appropriate use of generics.

That task is made easier by CarePatterns' information technology (IT) system, says Patrick McStay, vice president, business development of CarePatterns. "The system allows us to leverage the pharmacy claims information that we have access to." CarePatterns' IT platform allows care managers to review patients' pharmacy claims history during phone calls with the patients, Dodds says. The care managers "can address opportunities around generic promotion and be able to live transfer [patients] to pharmacists if necessary."

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