Clinical and Health Affairs
Collaborative Psychiatric Consultations
Guidance for Primary Care Providers Who Prescribe Psychotropic Medications for Children
By Mary Beth Reinke, Pharm.D., Glenace Edwall, Psy.D., Ph.D., Pat Nygaard, Ph.D., and John Zakelj
■ A 2010 Minnesota law required the Department of Human Services to develop a collaborative psychiatric consultation service for primary care practitioners and other health care professionals, with an initial focus on those who prescribe medications for children. Use of the service will be required for prescribers of certain psychotropic medications for children enrolled in fee-for-service Medical Assistance, the state’s Medicaid program. This article discusses the impetus for the law, explains the new medication review requirements, and describes plans for the consultation service.
In 2009 and 2010, Minnesota lawmakers were looking for ways to improve services and save money. Two ideas relating to psychiatric services received considerable attention: providing rapid access to psychiatry services for adults and requiring providers who care for children needing certain psychiatric medications to consult with a psychiatric expert before prescribing them. A bill proposing those services did not pass in 2009, but a revised version was brought back in 2010. Whereas the scope of the original legislation was limited to requiring consultations when prescribing psychiatric medications for children in Medical Assistance (MA), the state’s Medicaid program, the 2010 legislation was more broad in that it included provisions for voluntary consultations for both children and adults, as well as rapid access to direct psychiatric services for children and adults in certain situations.
During hearings on the 2010 bill, the Department of Human Services (DHS) presented data from the St. Cloud area showing that inpatient costs for children from school districts that participated in a project demonstrating the use of a collaborative consultation approach were less than those in districts that did not participate.1 The approach used in that project included screening for mental health concerns in primary care settings, using evidence-based primary care management protocols for common psychiatric conditions in children, and providing access to child psychiatrists for case consultation.
In addition, the DHS presented data from the state of Washington that showed the cost of pediatric psychiatric consultations is more than offset by savings from reductions in inappropriate medication use.2 The Minnesota Legislature also considered other evidence including findings from a 2008 report by the Minnesota Council of Health Plans, which analyzed claims data for 2.5 million Minnesotans enrolled in public and private health plans during 2005.3 The report noted that:
- Nearly one in 10 children and adolescents ages 20 years and younger in Minnesota has a mental health diagnosis;
- Ninety-seven percent of children receiving antidepressants do not receive follow-up care recommended by the Food and Drug Administration (FDA);
- One of 15 people with a mental health diagnosis visited an emergency room or was hospitalized (the most expensive forms of care) at least once during the year; and
- More than 80% of the drugs used to treat mental illness in Minnesota are prescribed by family medicine, internal medicine, and OB/GYN physicians; only 20% are prescribed by psychiatrists.
Based on these and other findings, the Minnesota Legislature approved an ongoing appropriation of $1 million per year starting in 2011 to create a collaborative consultation service, with the cost expected to be fully offset by reduced inpatient and medication costs. Physicians would call the service in order to receive guidance and authorization for prescribing certain psychiatric medications for children enrolled in fee-for-service MA.
What the Law Requires
The 2010 Minnesota Legislature directed the DHS to undertake three concurrent and related activities:
- Appoint interdisciplinary workgroups to establish appropriate medication and psychotherapy protocols to guide the consultative process;4
- Issue a request for proposals for collaborative psychiatric consultation and related services (the legislation allows DHS officials to select the structure and funding method that would be most cost-effective; this may include direct provision of services by the state, a public-private partnership with a provider organization, or a grant or contract awarded to a provider organization);5 and
- Identify situations for which a collaborative psychiatric consultation and prior authorization should be required before the initiation or continuation of psychiatric drug therapy in pediatric patients who have fee-for-service coverage in Medical Assistance.6 In other words, before pediatric patients can be prescribed those drugs, their providers will need to use the new collaborative psychiatric consultation service.
The goals of the service are to 1) improve the quality of mental health treatment by encouraging the use of evidence-based treatments in addition to or in place of medication where appropriate, 2) increase access to care and the quality of that care by making more efficient use of both primary care and specialty mental health services, and 3) foster collaboration between primary care and behavioral health services.
The consultation service would be available to primary care providers, emergency department personnel, local crisis services staff, and mental health professionals. Cases involving children on fee-for-service MA would receive priority, followed by those involving children who have other forms of health insurance. Primary care providers will be able to bill MA for the time they spend obtaining a psychiatric consultation.7
Establishing the Medication Authorization Thresholds
From December 2010 through March 16, 2011, the DHS convened the Drug Thresholds Workgroup, which included specialists in child psychiatry, pediatrics, behavioral pediatrics, and family medicine, to establish thresholds for various drugs by age group, above which would require a psychiatric consult as part of the prior authorization process. The workgroup also discussed 1) off-label prescribing and whether there should be a diagnosis on the prescription claim; 2) use of multiple drugs or dose forms within a drug class; and 3) how to better ensure that monitoring occurs for medical issues such as metabolic risks associated with atypical antipsychotics. Using the American Academy of Child and Adolescent Psychiatry Practice Parameters, the FDA-approved uses and recommended doses for various age groups, and practitioners’ clinical experience, they established dose thresholds for various age groups for atypical antipsychotics as well as for drugs used to treat attention deficit disorder and attention deficit hyperactivity disorder (Table 1 and Table 2).
For newer antipsychotics such as Fanapt, Saphris, and Latuda as well as for those that have yet to be developed, the workgroup recommended following the FDA guidelines regarding use in children and for treating certain conditions. Other uses and doses would require a psychiatric consult. The rationale for the consult is that existing atypical antipsychotics should be considered first-line therapy because they have a proven track record. The FDA-approved adult threshold could be considered the dose limit for the 13- to 17-year-old age group after trying existing atypical antipsychotics without benefit.
Additionally, duplicate therapy with two or more atypical antipsychotics for more than 60 days and with three or more mood stabilizers for more than 30 days will require a consultation.
Developing the Service
The DHS established the Children’s Psychiatric Consultation Protocols Workgroup in January 2011 to guide the design and development of the service. The group includes representatives from the Minnesota Psychiatric Society, Minnesota Society of Child and Adolescent Psychiatry, American Academy of Pediatrics-Minnesota Chapter, Minnesota Academy of Family Physicians, Minnesota Chapter-National Association of Pediatric Nurse Practitioners, American Psychiatric Nurses Association-Minnesota Chapter, Minnesota Psychological Association, Minnesota Chapter-National Association of Social Workers, other mental health provider and advocacy groups, and consumer and parent groups. A subgroup was convened to develop a method for triaging calls to ensure rapid response to mandatory medication reviews and critical psychiatric concerns.
Separate subgroups were convened to design protocols for the psychiatric consultations based on current research and practice standards to assist primary care physicians in determining what steps to take to ensure patient safety, how to screen for specific disorders, and when to refer to a mental health professional for assessment or treatment. Thus far, protocols have been developed for depression, anxiety, trauma, disruptive behavior, ADHD, bipolar disorders, eating disorders, and substance abuse.8 Additional protocols will be developed for autism and psychotic disorders.
Selecting a Vendor
On June 6, 2011, DHS issued a request for proposals for a provider to administer the collaborative psychiatric consultation service. The provider will not only be expected to provide the consultation services, but also will be required to coordinate this new service with health care homes and other services offered by health plans such as HealthPartners and PrimeWest. It also will need to conduct a variety of outreach and training activities to inform primary care providers and others about the new service. Department of Human Services officials are expected to select a vendor later this month. Once a provider is chosen, the new authorization requirements will be phased in for children in the fee-for-service MA program.
How the Service Will Work
Many of the details regarding this new service will be worked out after a vendor is selected. The way it is expected to work is that the vendor will operate a call center that will be available statewide Monday through Friday from 7 a.m. to 7 p.m. A triage professional, most likely a licensed social worker, will answer calls and determine the most appropriate response to each request. Requests for medication authorization and/or collaborative psychiatric consultation will be routed to on-call psychiatrists who have qualifications specific to the request. For example, all requests relating to children’s psychiatric medications will be handled by board- certified child and adolescent psychiatrists. The protocols developed by the Children’s Psychiatric Consultation Protocols Workgroup will be used to guide the consultations.
Based on September 2010 fee-for-services claims, an estimated 16% (n=480) of children with MA fee-for-service coverage would exceed atypical antipsychotic thresholds and 5% (n=391) would exceed stimulant and atomoxetine drug thresholds during the first month. In order to not overwhelm the service, implementation will progress gradually.
Initially, 90% of the services will be provided for patients younger than 21 years of age. Consultations for both ADHD drugs and atypical antipsychotics initially will be mandatory for children under 5 years of age. Voluntary consultations for children and adults are expected to make up a larger share of the caseload in the future as prescription patterns for children are expected to change, thus reducing the need for mandatory consultations and freeing up resources for voluntary consultations.
Department of Human Services officials will track the cost of the consultation services provided and monitor the effect of the program on emergency room utilization, inpatient psychiatric hospitalizations, use of psychotropic medications, use of residential and day treatment, partial hospitalizations, use of outpatient therapies and rehabilitation services, and use of other health care services. In addition to tracking costs and utilization, they will measure whether access to and quality of treatment improves as a result of better collaboration between primary care and behavioral health providers.
Conclusion
Minnesota’s collaborative psychiatric consultation service is being developed to assist physicians who prescribe psychotropic medications for children covered by the state’s MA program. It is expected that this service will lead to better outcomes for young patients with mental health concerns and lower health care costs for the state. MM
Mary Beth Reinke is drug utilization and review coordinator in the Minnesota Department of Human Services’ (DHS) Pharmacy Unit. Glenace Edwall is director of the Children’s Mental Health Division; Pat Nygaard is quality and performance manager in the Children’s Mental Health Division, and John Zakelj is the psychiatric consultation project manager for DHS.
The authors thank Jeff Schiff, M.D., for his guidance and assistance on this article.
References
1. Sulik LR, Willis L, Edwall G. Integrating Primary Care and Mental Health Services for Young Children: The Great Start Minnesota Project, Early Childhood Mental Health Screening and Models of Pediatric Integrative Behavioral Health Care, Poster Presentation, Connecting for Children’s Sake, Integrating Physical and Mental Health Care in the Medical Home. The 2005 Peds-21 Symposium on Mental Health, Pediatrics in the 21st Century Symposium Series, American Academy of Pediatrics Annual Meeting, October 7, 2005, Washington, DC.
2. Thompson JN, Varley CK, McClellan J, et al. Second opinions improve ADHD prescribing in a Medicaid-insured community population. J Am Acad Child Adolesc Psychiatry. 2009;48(7):740-8.
3. Minnesota Council of Health Plans: Minnesota’s Mental Health, February 2008. Available at: mnhealthplans.org. Accessed September 16, 2011.
4. Minnesota Statutes 245.4862, subd. 4
5. Minnesota Statutes 245.4862, subd. 7
6. Minnesota Statutes 256B.0625, subd. 13j
7. Minn. Statutes 256B.0625, subd. 48
8. Minnesota Department of Human Services: Protocols Workgroup Meeting Notes and Draft Flowcharts. Available at: www.dhs.state.mn.us/psychconsult. Accessed September 16, 2011.