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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

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Underwriting with Prescription Histories Across the Mental Health Continuum

Scott Coller, Pharm.D. – Pharmacy Consultant Midwestern Underwriting Conference 21 September 2016

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

Agenda

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Drug therapies impact many neurotransmitters.

Drug Name Dopamine Histamine Norepinephrine Serotonin Acetylcholine Glutamate GABA

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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.

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There are a few key categories of psychotropic meds.

Antidepressants and Anxiolytics
Antipsychotics
Mood Stabilizers
Others
Stimulants
Cognitive Enhancers

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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

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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.

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

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A Sesame Street Mnemonic for Mental Disorders

Insomnia Depression Obsessive Compulsive Disorder (Anxiety) Bipolar Disorder Schizophrenia

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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.

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How Medications Treat Insomnia

Benadryl
Trazodone & Seroquel
Melatonin
Rozerem
Temazepam & Ambien
Belsomra

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Major Depressive Disorder (MDD)

Low mood, low self-esteem, loss of interest
Targets:
Norepinephrine, Serotonin, Dopamine
SSRI, SNRI
Bupropion
Tricyclic
MAO-I
Antipsychotic

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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

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How Medications Treat Anxiety

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

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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

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Bipolar Disorder

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

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Estimating Bipolar Progression

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

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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

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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

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Rule engines can manage relative mortality.

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What is RxRules?

RxRules Data 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

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

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Underwriting expertise remains critical.

Accept Decline Review

RxRules

Data Input

Rx info
App data
Other (MIB, MVR)

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Interpreting a long list of psych meds? Yikes!

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Fill details provide insight to conditions and severity.

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A rule engine supports easy decision-making.

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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!

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