Underwriting with Prescription Histories Across the Mental ... · How Medications Treat Insomnia...

Underwriting with Prescription HistoriesAcross the Mental Health ContinuumScott Coller, Pharm.D. – Pharmacy Consultant

Midwestern Underwriting Conference

21 September 2016

Psychotropic Medications

Rule Results, UW Guidelines and Decisions

Rule Engines Interpret Psych Meds

Drug Combinations and Mortality

Medications and Disease Progression

Agenda

Drug therapies impact many neurotransmitters.

Drug NameDopamineHistamineNorepinephrineSerotoninAcetylcholineGlutamateGABA

Dopamine & Histamine

Cognition(Mental Alertness)

Norepinephrine & Acetylcholine

Vigilance(Sustained Concentration)

Serotonin & Glutamate

Perception(Sensory Satisfaction)

Appetite Intuition

Attention

MOOD

GABA

Neurotransmitters influence a wide range of mental states.

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

Insomnia

Nausea

Neuropathy

Migraine Prevention

Tourette’s

Obsessive/Compulsive

Bipolar

Schizophrenia

ADHD

Benzodiazepines

SSRI’s, SNRI’s

Tricyclics, Tetracyclics, Modified Cyclics

Antipsychotics

Anticonvulsants

Stimulants

GABA Analogs

Bupropion

Epilepsy

Benzodiazepines

SSRI’s, SNRI’s

Tricyclics, Tetracyclics, Modified Cyclics

Antipsychotics

Anticonvulsants

Stimulants

GABA Analogs

Depression

Anxiety

Insomnia

Nausea

Neuropathy

Migraine Prevention

Tourette’s

Obsessive/Compulsive

Bipolar

Schizophrenia

ADHD

Smoking Cessation

Bupropion

Underwriters use Rx histories to interpret conditions.

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

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†

Insomnia

†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 agentSSRI or SNRI

Multiple agents, non-concurrentTrial and transition

Multiple agents, concurrentAD + BZD

Multiple AD

AD + AP

AD + AC

How Medications Treat AnxietyGAD, Panic, Social Anxiety, Phobias, OCD, PTSD

Targets:GABA Serotonin

SSRI, SNRI, TCA

Benzodiazepines

GABA analogs

Buspirone

Antipsychotic

Estimating Anxiety ProgressionSSRI for maintenance with benzodiazepine for breakthrough / symptomatic relief

Benzodiazepine monotherapy

Pregabalin or buspirone monotherapy

Multiple agents, concurrent

Combinations of aboveAnticonvulsantsAntipsychotics

Bipolar Disorder

Periods of mania/hypomania alternating with depression

Bipolar I, Bipolar II, Cyclothymia, Mixed, Rapid Cycling

Estimating Bipolar ProgressionStarting therapy:Lithium and/or Depakote +/- antipsychoticLithium 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 onClozaril is probably most effective

Three-quarters of all patients stop taking their medications

Rule engines can manage relative mortality.

What is RxRules?

RxRulesData Input Rx info Application data Other (MIB, MVR)

UW Guidance Conditions Severity 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

Insomnia Treatment

Possible

Treatment-resistantDepression

PossibleBipolar

Treatment Likely

Schizophrenia Treatment

Likely

RxRules

Underwriting expertise remains critical.

Accept

Decline

ReviewRxRulesData Input

Rx info App data Other (MIB, MVR)

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, PharmDscott.coller@milliman.com

262-641-3527