An Integrated Approach to the Improvement of Psychoactive Prescribing Practices for the Oregon Health Plan

By Peter Davidson, MD. – about 2001


The increasing cost of psychoactive drugs is threatening any program at risk for
these drugs and the OHP is no exception. Program managers everywhere are hoping to adopt
ethical strategies for managing the costs of psychoactive drugs. This can be done through
improvements in both access to care and in the effectiveness of prescribing practices.

The issue of whether a problem with prescribing practices driving these cost
increases is debatable. This proposal assumes that such a problem does exist as detailed
below. If this is true, then the question becomes, how can program managers change
physician prescribing behavior?

To date, most attempts have failed. Over the long term, physicians have been
remarkably successful in resisting overt attempts to control their behavior. There is a
common though not entirely obvious reason for this. Methods such as formularies, prior
authorization and rigid ‘best practice’ rules make life more difficult for prescribers and
their patients.

Experienced clinical administrators have found that making life difficult for
clinicians does not improve access, clinical outcomes, or cost efficiency. A successful
approach will make mental health care more accessible, more effective and easier to
from the perspective of both primary care providers (PCPs) and their patients.
This way of making life easier for OHP providers will result in better and therefore more
cost effective care.


This project is designed to accomplish three objectives:

1) Integrate the OHP mental health carve out and ‘somatic mental health’
treatment practices through a QA system organized around psychoactive drug prescribing.

2) Improve the effectiveness of psychoactive Rx prescribing practices.

3) Control the cost increases associated with outpatient psychoactive medication
prescribing in the OHP.

Improvements in the delivery of mental health care in primary practice settings
should produce the projected cost savings. This hypothesis is based on the following

(1) The cost increases in psychoactive prescriptions are not due entirely to the
costs of the drugs themselves, i.e., that there are an ever larger number of people being
prescribed psychoactive medication and for longer periods of time.

(2) As psychoactive drugs have become both safer and are now directly marketed
to the public, an increase in the number of prescriptions written in lieu of more
effective (psycho-social) intervention has occurred.

(3) Since many of the new, more expensive drugs are better tolerated, people may
tend to stay on them longer than necessary.

(4) Physicians tend to prescribe to a “no further complaints” endpoint
and not to the point of maximizing a patient’s functional capacity.

(6) Better clinical outcomes in the primary care setting will reduce costs in
other parts of the mental health budget, such as ER, in-patient and carve-out (MHO) based

(7) An integrated QA effort will help to curb wasteful health care delivery
practices caused by poorly integrated clinical care.

Both the practitioners employed by Fully Capitated Health Plans (FCHPs) and by
the carved out Mental Health Organizations (MHOs) provide mental health care to OHP
Members. The goal of Quality Assurance in this context is to ensure that ‘somatic mental
health care’ practitioners of the FCHPs and MHO Providers integrate their efforts in order
to provide the highest possible level of access and treatment outcome to OHP Members. The
method will involve the integration of both clinical services and Quality Assurance


Integration of Clinical Services

Services to OHP Members classified as ‘somatic mental health’ care will be
enhanced by the addition of new programs and policies, including the following:


A Consult Liaison Service

An adult and a child psychiatrist will be ‘on call’ by phone, fax, beeper and
e-mail to any OHP practitioner in the participating region.

These people will be available to discuss any aspect of behavioral health care
including, but not limited to:

  • Diagnostic dilemmas
  • Psycho-social or behavioral complications of medical illnesses
  • Prescribing of psychoactive Rx
  • Drug interactions
  • Axis II and/or Challenging Behavior problems
  • Accessing further consultation/mental health services locally
  • Crisis interventions
  • Forensic risk management


Reports and Information Service

Each prescriber will be supplied with an activity log including the number of
OHP Members seen, the amount and classification of Rx prescribed to them, hospitalization
rates, diagnostic data as it becomes available, volume trends in graphic form, normative
data for comparison of practice to others in comparative regions. These reports will be
for informational purposes only.


MHO Provider Outreach Services to FCHP Prescribers

MHO Providers will institute a ‘no refusal’ outreach protocol for all OHP
Providers. This means that MHO Providers must respond with an immediate, face to face
psychological intervention with any OHP Member at the request of any prescriber seeing an
OHP beneficiary.

In rural areas, the outreach worker will likely be the on-call crisis person. In
urban areas or larger towns, some Providers will hire people whose job it will be to
deliver mental health care at OHP Provider offices (at the request of the Provider, of


Prevention and Education Services

Participating practitioners will be provided with the latest information on
services and programs available in the community which are available to promote the health
of OHP Members. The program will continuously distribute the latest news on prescribing
practices from scientific literature as well as from OMAP databases.


Integration of QA Activity

The Quality Assurance Plan’s of the participating MHO and FCHPs will be amended
to produce a uniform approach to the mental health care delivered by their practitioners.
There will be a combined approach to quality standards, definitions and quality
improvement activities.

MHO and FCHP Providers will participate in QA efforts to the extent that they

  1. Adhere to standards of integrated health care practices (listed below),
  2. adhere to standards of documentation for prescription of psychoactive Rx,
  3. supply QA staff with charts for auditing purposes, and
  4. comply with Corrective Action recommendations when quality thresholds are not


Outcome Based Psychoactive Drug Prescribing

The role of physicians is to first, do no harm, second, to heal and third, to
relieve suffering when healing is not possible. With regard to psychopathological
processes, the measure of healing is in the improvement of a person’s ability to function
in life. In other words, simply “feeling better” without functioning better
(palliation) is not a legitimate therapeutic goal, unless true healing is not possible.

Prescribing standards must allow for creativity and innovation at the same time
that they ensure that any drug or combination of drugs which is not producing the desired
clinical effect are discontinued or otherwise changed.

With this in mind, the integrated QA Plans must adopt the following
documentation requirements for the prescription of psychoactive drugs.

  1. The ongoing prescription of any psychoactive medication must be accompanied by
    the documentation of positive effect(s) on life functioning, as defined below.
  2. A positive treatment outcome must be described in terms of the functional
    disability which the Rx is intended to eliminate or ameliorate.
  3. In general, a subjective sense of improvement, from either the patient’s or the
    clinician’s perspective is not a functional improvement, unless the ‘subjective sense’
    allows the patient to, in some observable way, function at a higher level in a basic life
    domain, including but not limited to: (a) intimate/family relationships, (b) peer/social
    relations, (c) vocational/school, and (d) ADLs/life skills.
  4. In some but not all instances, a behavior and/or a symptom of an illness may be
    synonymous with a functional disability.
  5. In that Rx can cause negative effects which diminish functional capacities, drug
    choices and doses must be demonstrated to be producing beneficial effects which clearly
    outweigh negative effects. Documentation must demonstrate that the functional benefit(s)
    of a drug or combination of drugs must outweigh the drug(s) deleterious effects on
    functional capacities.
  6. If the prescriber has determined that there exists a high risk of functional
    disability associated with relapse, indefinite continuation of Rx is recommended. In this
    case, this opinion must be documented in addition to a statement to the effect that the
    dose(s) are optimized in terms of the risk of relapse/breakthrough Sxs on the one hand,
    and the risk/degree of negative drug effects on the other. In other words, the dosage of
    drug(s) must be minimized to the safest level possible.


Integrated Standards of Clinical Practice

For the purposes of the project a ‘Provider’ is defined as: Anyone who provides
prepaid mental health or somatic mental health services to OHP members under contract
with, or employed by the MHO or the FCHP.

I. Providers will engage in joint planning and implementation of treatment
services with community agencies and other Providers through ongoing communication links,
so as to respond quickly and flexibly to changes in the Member’s clinical condition.


II. Providers will work directly with community agencies and Members’ natural
systems of support in order to ensure ‘community ownership’ of OHP Members prior to
reduction in treatment intensity or termination from services.

III. When co-occurring chemical dependency and/or somatic health, and/or mental
health problems exist, treatment of these conditions will be integrated and simultaneous.

IV. Providers will ensure coordinated treatment delivery with other Providers,
including at a minimum, an ongoing exchange of medical records whenever medication is
prescribed or changed.


The Focus on Effectiveness

The purpose of this integrated approach to managed care is to improve the
effectiveness of service, as opposed to limiting to type or intensity of services. Toward
this goal, the focus of the chart reviews will be on quality of the content and not on
‘compliance’ with a narrow set of documentation regulations. It is not that compliance
with applicable documentation rules is no longer necessary. Most documentation rules,
however, do not bear on the quality of the delivered service and are therefore not a focus
of this effort.

Chart audits associated with the above listed documentation requirements will be
conducted only by licensed clinicians under close supervision by doctoral level clinical
administrators. This approach to QA will involve clinicians who have no direct knowledge
of the actual case judging the work of the clinicians who do. Because of this fact, the
basis for any critique of the quality or ‘appropriateness’ of a clinical decision must be

For our purposes, ‘appropriate’ decisions are those which would be made by a
reasonably competent clinician given the known circumstances of the case and the current
standard of clinical care as established by peer reviewed professional journals.

Broad discretion will be granted to Providers by the QA staff in the judgement
of their clinical decisions when (1) no particular standard of care has been established
for a given clinical situation, when (2) ordinary interventions, decisions, or attempts
were made but failed, and (3) when to use established standards of care would conflict
with common sense, the law, or other clinical care standards of higher priority.

It is important to note that prescribers will not be asked to produce clinical
documentation or justification of clinical practice outside of that ordinarily required by
accepted standards of clinical documentation associated with the OHP.

QA methods can not improve clinical care if the clinicians and the QA people do
not trust each other . Getting prescribers to not only tolerate, but actually include
themselves in this program will be a key to its success. Physician to physician contact
will occur whenever special circumstances, complaints, communication problems, data base
outliers, and other questions arise.


Judging the OUTCOME of the MHO/FCHP Integrated QA Project

There are three essential elements of Quality.

I. Access to Services

II. Clinical Efficacy. [This involves the measurement of how well the OHP
benefit has worked for Members.]

III. Therapeutic Efficiency. [The therapeutic results (the product of Domains I
and II) to cost ratio is a measure of our efficiency in the use of OHP dollars.]

This third element is an often neglected but fundamental part of assessing
clinical programming. Any program which can deliver equal clinical results (access and
outcome) for less tax dollars is superior to any more costly method.

This project is an attempt to improve all three of these Quality elements

We are hoping to demonstrate how we can produce improvements in Efficiency (cost
savings) by creating improvements in Access and Clinical Efficacy. A simultaneous
comparison of the effect of this project in these three areas will tell us whether the
program was successful when compared with existing OHP programs.


I. Measuring Access

The project has been designed to improve OHP beneficiary access to mental health
treatment as well as Prevention, Education and Outreach services. If the project works as
planned, we should see earlier intervention for more OHP eligibles. The are several data
sources we will be using to perform a prospective assessment of any change in access
associated with this project.

Member Satisfaction Survey

Community Stakeholder Satisfaction Survey

Access related Complaint rates

Penetration Rates

Prevention Education and Outreach encounter data.

One aspect of access which can not be measured directly despite its critical
importance to clinical outcome and cost efficiency, is how early treatment or
PE&O services got to a person in trouble. This project is, however, designed to get
these services to those Members who first bring their emotional or behavioral complaints
to FCHP Providers more rapidly than is likely through the existing referral and
consultation based system.


II. Measuring Clinical Efficacy

Rates of hospitalization, complaints, adverse incident reports and surveys of
beneficiaries and community stakeholders are the most often used methods of assessing
whether treatment or prevention and outreach efforts are effective. These surveys are
conducted annually throughout the duration of the pilot. Serial measures of the listed
rates will be produced quarterly for trend analysis.

A group of matched controls receiving ‘treatment as usual’ will be compared
prospectively, using functional capability and quality of life measurement instruments,
with a group of OHP beneficiaries whose care was associated with this project. This type
of measurement is important because the project has, imbedded within its standards of
care, a definition our treatment goal: improve people’s interdependent functional ability
within their natural system of care and support. This goal is behind programs which use
the Community Rehabilitative care model embraced by the MHDDSD of Oregon’s DHR.


III. Measuring Efficiency

We must be able to measure whether the project has (a) paid for itself and (b)
whether the costs associated with the care of OHP beneficiaries in the project were more
or less than those associated with matched controls receiving treatment as usual.


Project Cost Categories

  1. Report writing and distribution
  2. Consult Liaison service
  3. Quality Assurance activities
  4. Administrative support
  5. Psychoactive drug costs: (a) 7 & 11 categories, from OMAP data and, (b) the
    10, 12 & 48 categories from OMAP and/or FCHP data
  6. Outreach services to FCHP providers. These costs will be captured from the
    fee-for service billing to the MHO from Providers who actually deliver these services.

Figuring out whether the cost of care was increased or decreased must employ an
equation including all variables associated with the cost of care. As examples,
hospitalization costs, drug costs, the costs of treatment procedures including ER and
office visits all may change as a result of this program


Questions and Answers

What next?

All approaches to drug cost containment have startup costs. This approach
involves no new bureaucracies, but it does involve service level increases to OHP
beneficiaries at the PCP level. OMAP as well as the participating FCHP(s) and MHO(s) would
have to get together to figure out how to fund the project. A pilot project makes sense
because it would be easier to implement and study its effectiveness.


Why would prescribers choose to participate?

While it is true that physicians prefer complete autonomy of practice, as a
practical reality, that possibility does not exist. The real question is what kind of
management practices physicians prefer. If this type of approach can prevent the
institution of formularies, rigid best practice algorithms and the like, then perhaps
physicians will embrace it as the least intrusive alternative.

The program is designed to aid PCPs in the care of the population most of them
find most difficult to handle. No other cost containment approach is designed to make the
life of the OHP physician easier.


Won’t there be a lot of arguing about what constitutes a functional improvement?

No. As detailed above, broad discretion in this regard will be granted to
prescribers, especially when the Integrated Standards of Clinical Practice are well

There would be no micro-management of individual situations or second guessing
of documented clinical opinions.


Who loses?

Perhaps a win-win is not entirely possible, but this type of approach is least
likely to produce painful consequences. This is because it is based in the idea that
improving the functional capacity of OHP beneficiaries will save DHS and the taxpayers

Due to case finding effects and the general superiority of certain new and
expensive medications, cost savings might not accrue in each of the various drug budgets.
The odd carve out of the 7 & 11 drug budget for example, should not mean that this
type of approach be judged solely in terms of its effect on that budget.

DHS populations move freely between budgets managed of necessity by separate
bureaucracies. This means that the cost effectiveness of an integrated management approach
must also be integrated, perhaps using a wider set of DHS/OHP cost measures than those
listed above. At some point however, one loses the causal connection when too broad a set
of measures are applied.

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