Minutes
Drug Utilization Review (DUR) Board Meeting
September 09, 2009		

Meeting Purpose: Quarterly Open Board Meeting
Meeting opened at 6:00 P.M. by Chair, Dr. Andrew Balder.

Agenda Items:

I.	Acceptance of the June 2009 DUR Board Minutes
II.	Synagis Update (CY 09-10)
III.	Antipsychotic Initiative
IV.	Novel H1N1/09 Update
V.	Proton Pump Inhibitor Initiative
VI.	MassHealth Drug List
VII.	DUR Operational Update
VIII.	MassHealth Update	                                   Dr. Paul Jeffrey, MassHealth

Agenda Item	Discussion	Conclusions/Follow Up	
I.  Acceptance of the June 2009 DUR Board Minutes		Conclusions
Minutes approved as written.
	
 Action 

	A motion to approve the June 2009 minutes was made and seconded.

	Follow up

Agenda Item	Discussion	Conclusions/Follow Up	
II. Synagis Update (CY 09-10)

	Background: American Academy of Pediatrics (AAP) recommendations were revised for 2009.  Medical evidence, anticipated impact, preparation for upcoming season, and conclusions were presented.  

A preliminary cost analysis was conducted to determine potential impact of the new criteria.  A pool of all approved doses from 2008-2009 season was reviewed.  The new criteria was applied to determine the number of members affected and potential cost avoidance.	Conclusions

The Respiratory Syncytial Virus (RSV) season is rapidly approaching.  There are new AAP recommendations for the use of Synagis in RSV prophylaxis. 

It is anticipated that there will be little impact on the number of members yet there is potential for significant cost avoidance.

Results of preliminary cost analysis: 36 members affected; $275,912 in cost avoidance.
	
Action

	MassHealth will consider adopting the new AAP recommendations.

MassHealth seasonal quantity limits for Synagis were lifted.

	Follow up

Guidelines will be revised as necessary.	

Agenda Item	Discussion	Conclusions/Follow Up	
IIII.  Antipsychotic Initiative
	The number of claims from 1/31/09 to 6/30/09 was presented.  The MHDL web site also posted the claims paid and the amount of dollars paid by MassHealth during the same period. Draft prescriber letters for quetiapine (Seroquel) and paliperidone (Invega) were presented and will be mailed once they are approved. It was noted that 23% of MassHealth members receiving Seroquel are receiving doses less than 200 mg/day. A table comparing risperidone to paliperidone was presented. It was noted that the chemical structure of the products is very similar. The side effect profile shows no demonstrated differences; the clinical efficacy showed no demonstrated differences, yet the cost for a prescription of risperidone is $36 compared to that of paliperidone which is $274. Projected yearly cost avoidance for MassHealth would be significant if risperidone is used rather than Invega.

It was noted that behavioral health pharmacy management issues can be confusing to providers, especially with Part D and MassHealth guidelines and rules. 
	Conclusions

Communication is paramount with this expensive drug class and to educate is a successful way to manage use. Changes can be found on the web site http://www.mass.gov/masshealth/pharmacy.
	
Action

	Proposed next steps include:
•	Provide outpatient medication profile to inpatient treating provider
•	Polypharmacy and other letters
And perhaps a low dose ziprasidone letter?
	Follow up
The results of the educational interventions will be reported back to the DUR Board.	

Agenda Item	Discussion	Conclusions/Follow Up	
IV.  H1N1/09  Influenza Update	Differences between seasonal influenza and H1N1/09 were highlighted.  Patient populations who should receive the H1N1 vaccine were defined. Trends for the 2008-2009 influenza season were highlighted and the latest CDC recommendations for the treatment of H1N1 were identified.  

H1N1 vaccine target population is made up of:
•	pregnant women
•	household contacts and caregivers for children ≤ 6 months old
•	healthcare and emergency medical workers
•	individuals 6 months-24 years old
•	individuals 24-64 years old with chronic health disorders or immumosuppression

Tamiflu and Relenza treatment options were presented.  	Conslusions

Youth are more at risk. Only high risk patients should be vaccinated. Children require two doses with approximately 21-28 days between first and second vaccination. This may be administered the same day as seasonal influenza vaccine. Again, education is a priority. We will know more once studies are completed.

	
Action
Agenda I

tem	Discus
	Follow up

	

Agenda Item	Discussion	Conclusions/Follow Up	
			
V. Proton Pump Inhibitor (PPI) Initiative

Action

	 The presentation of this prescriber outreach initiative included reviewing ways of looking at patient profiles for proper use of long term PPI therapy, looking at potential risks associated with long term acid suppression, highlighting different options available to limit the use of PPIs, reviewing a successful program utilizing options presented, and outlining the project proposal to provide outreach to prescribers with patients on chronic PPI therapy. 

The inappropriate treatment of GERD, gastric ulcer and active duodenal ulcers were covered along with increased risks associated with chronic acid suppression including gastric cancer (conflicting data), community acquired clostridium difficile associated disease, community acquired pneumonia, hospital acquired pneumonia, and bone fractures.

PPI management options were reviewed including step up therapy, step down therapy and on-demand therapy.  

PPI initiatives have taken place in Washington and North Carolina.	Conclusions

MassHealth will continue to strive for optimal quality and safety regarding this topic. 

Follow up

Assessment :
•	identify utilization within same population six months after outreach;
•	prepare updated data reports and evaluate outreach opportunities twice yearly; and
•	overall goal: to save Massachusetts 10% cost avoidance.	
VI.  MassHealth Drug List Updates

Action
	Effective November 2, 2009, there will be 24 new additions to the MassHealth Drug List. Changes in Prior Authorization effective 11/02/09 will include Xyrem and Firmagon. Maintenance doses of Suboxone ≤ 16 mg/day will no longer require prior authorization. Changes in PA status effective 11/16/09 will include Acetasol, Ciprodex Otic suspension, Cipro HC OTIC suspension and Floxin OTIC singles. The PA requirements for Flumist and Adderall XR have also been modified. Changes in the MassHealth Drug List  therapeutic class tables effective 11/2/09 will include:
•	Tables 2, 3, 13, 25, 29 and 46.	Conclusions

MassHealth will continue to report changes to the Drug List on a regular basis.

Follow up

	

Agenda Item	Discussion	Conclusions/Follow Up	
VII. DUR Operational Update	There was a spike in March call volume numbers due to an extra week in the month. A lower abandonment rate reflected the fact that there are five people accepting phone calls at any one time. Between July 2008 and July 2009, the number of prior authorizations was highest in October 2008. The number of appeals between July 2008 and July 2009 was greatest in May 2009.  The lowest number in December 2008. 
 	Conclusions

Overall, numbers remain consistent.

Action 

		Follow up

Agenda Item	Discussion	Conclusions/Follow Up	
VIII.  MassHealth Update
Dr. Paul Jeffrey	Reports on the budget are not positive.  The MassHealth projected budget was $8.9 B with a $9.5 B projected spend. Strategic planning retreats are taking place with a focus on how the state can save money while preserving services and rates. We spend 42% of our funds on 3% of our patient population. There are some strategies in development on how to lower costs with this group of members.

We finished FY09 with lower pharmacy spending than projected, as we did the previous two years.  Opportunities do exist to save dollars but they are small scale.  

The Medicaid Director announced his resignation effective September 18, 2009, and it is not known what will happen with his projects.  This will all have to be worked out. 

There will be continued focus on how to spend our dollars wisely.	Conclusions

	
Action 

	Dr. Jeffrey will continue to keep the group apprised to the status of the FY10 budget, strategies, planning and happenings as they occur.
	Follow up

Meeting adjourned at 7:40 pm.

Respectfully Submitted,

Vincent Palumbo, R.Ph.
DUR Program Director