Underwriting with Prescription Histories Across the Mental Health - PowerPoint PPT Presentation

Underwriting with Prescription Histories Across the Mental Health Continuum Scott Coller, Pharm.D. – Pharmacy Consultant Midwestern Underwriting Conference 21 September 2016

Agenda Psychotropic Medications Medications and Disease Progression Drug Combinations and Mortality Rule Engines Interpret Psych Meds Rule Results, UW Guidelines and Decisions

Drug therapies impact many neurotransmitters . Drug Name Dopamine Histamine Norepinephrine Serotonin Acetylcholine Glutamate GABA

Neurotransmitters influence a wide range of mental states. Dopamine & Norepinephrine & Histamine Acetylcholine Attention Cognition Vigilance (Mental Alertness) (Sustained Concentration) MOOD Appetite Intuition Serotonin & Glutamate Perception (Sensory Satisfaction) GABA

There are a few key categories of psychotropic meds.  Antidepressants and Anxiolytics  Antipsychotics  Mood Stabilizers  Others  Stimulants  Cognitive Enhancers

Doctors prescribe by condition. Depression Anxiety Benzodiazepines Insomnia SSRI’s, SNRI’s Nausea Tricyclics, Tetracyclics, Modified Cyclics Neuropathy Antipsychotics Migraine Prevention Anticonvulsants Tourette’s Stimulants Obsessive/Compulsive GABA Analogs Bupropion Bipolar Schizophrenia ADHD

Underwriters use Rx histories to interpret conditions. Depression Anxiety Insomnia Benzodiazepines Nausea SSRI’s, SNRI’s Neuropathy Tricyclics, Tetracyclics, Migraine Prevention Modified Cyclics Tourette’s Antipsychotics Obsessive/Compulsive Anticonvulsants Stimulants Bipolar GABA Analogs Schizophrenia Bupropion ADHD Smoking Cessation Epilepsy

Rules engines can be used to map drugs to likely conditions.

A Sesame Street Mnemonic for Mental Disorders Insomnia Depression Obsessive Compulsive Disorder (Anxiety) Bipolar Disorder Schizophrenia

Insomnia  Fall asleep or stay asleep as long as desired  Symptom of another disorder  Functional impairment while awake  < 3 hrs or >10 hrs increases mortality by 50-100%.  7 hours per night: lowest mortality † † Kripke DF, et al. Arch Gen Psychiatry. 2002;59(2):131-136.

How Medications Treat Insomnia  Benadryl  Trazodone & Seroquel  Melatonin  Rozerem  Temazepam & Ambien  Belsomra

Major Depressive Disorder (MDD)  Low mood, low self-esteem, loss of interest  Targets:  Norepinephrine, Serotonin, Dopamine  SSRI, SNRI  Bupropion  Tricyclic  MAO-I  Antipsychotic

Estimating MDD Progression  Single agent  SSRI or SNRI  Multiple agents, non-concurrent  Trial and transition  Multiple agents, concurrent  AD + BZD  Multiple AD  AD + AP  AD + AC

How Medications Treat Anxiety  GAD, Panic, Social Anxiety, Phobias, OCD, PTSD  Targets:  GABA  Serotonin  SSRI, SNRI, TCA  Benzodiazepines  GABA analogs  Buspirone  Antipsychotic

Estimating Anxiety Progression  SSRI for maintenance with benzodiazepine for breakthrough / symptomatic relief  Benzodiazepine monotherapy  Pregabalin or buspirone monotherapy  Multiple agents, concurrent  Combinations of above  Anticonvulsants  Antipsychotics

Bipolar Disorder  Periods of mania/hypomania alternating with depression  Bipolar I, Bipolar II, Cyclothymia, Mixed, Rapid Cycling

Estimating Bipolar Progression  Starting therapy:  Lithium and/or Depakote +/- antipsychotic  Lithium and/or Lamictal +/- antidepressant  Maintenance:  Lithium, Depakote, Lamictal, Tegretol, Trileptal or Antipsychotics

Schizophrenia  Suicide Risk  At least 2 symptoms present for six months  Negative: Flat affect, lack of pleasure in daily life, lack of drive, speaks little  Positive: Hallucinations, delusions, thought disorders, movement disorders  Cognitive: Poor executive functioning, trouble focusing, problems with working memory

Estimating Schizophrenia Progression  Thought disorder, mood disorder, and anxiety disorder  Antipsychotics are first line but others may be added on  Clozaril is probably most effective  Three-quarters of all patients stop taking their medications

Rule engines can manage relative mortality.

What is RxRules? Data Input RxRules UW Guidance  Rx info  Conditions  Application data  Severity  Other (MIB, MVR)  Decisions Rule Variables  Indication / Therapeutic class  Drug combinations  Fill timing(date or duration ranges)  Fill counts / patterns  Dosage / quantity  Physician specialty / count  Gender / Age  Other variables

RxRules Schizophrenia Treatment-resistant Treatment Insomnia Depression Bipolar Likely Treatment Possible Treatment Possible Likely

Underwriting expertise remains critical. Decline Data Input RxRules  Rx info Review  App data  Other (MIB, MVR) Accept

Interpreting a long list of psych meds? Yikes!

Fill details provide insight to conditions and severity.

A rule engine supports easy decision-making.

Summary  There is a wide range of psychotropic medications used to treat a wide range of mental health disorders.  It is difficult to reverse engineer medications to determine likely conditions and severity.  A rule engine can bring consistency and efficiency to a very challenging job!

Thank you! Questions? Scott Coller, PharmD scott.coller@milliman.com 262-641-3527