Behavioral Health Partnership Oversight Council Coordination of Care Subcommittee
Legislative Office Building Room 3000, Hartford CT 06106
(860) 240-0321 Info Line (860) 240-8329 FAX (860) 240-5306
Meeting Summary: November 1, 2006
Chair: Sheila Amdur
Next meeting: date changed to Wednesday November 29 @ 9:30 in LOB RM. 3800
Sept meeting summary
Sheldon Toubman requested the Sept. summary be amended to include under Pharmacy discussion: Health Net representative acknowledged that the requested pharmacy data is available. There was no objection from the subcommittee to this request.
DSS opened the discussion of the proposed DSS pharmacy study by stating that the MCOs are deferring to DSS for guidance on pharmacy issues as the issues are part of the Freedom of Information (FOI) court case, the outcome of which is not yet decided by the court. The MCOs do not want to participate in the discussion individually.
DSS report on the proposed study:
• Rose Ciarcia (DSS) again outlined the steps taken by DSS/MCOs to clarify the temporary drug distribution by the pharmacies in the MCO network.
o Noted that CHNCT has a more automatic override for temporary supplies (TS),
o WellCare's new formulary process has a local pharmacy message similar to Anthem, Health Net. In addition, once the local pharmacy contacts WellCare because of a denial/rejection of a script, an automatic override for a temporary drug is always made.
o In February 2003 DSS sent a policy transmittal (PB 2003-12) to pharmacies participating in Medicaid clarifying when a TS of a prescribed drug should be dispensed. Sheldon Toubman noted the transmittal did not include the step that the pharmacy needs to call the PBM to get approval for dispensing the TS drug. Mr. Toubman noted that the complexity of the process is causing the low number of TS to be issued upon rejection of scripts at the pharmacy for all but CHNCT that has an automatic override.
• Subsequent to the last SC meeting, DSS and Mercer are conferring on a study design that will include rejected scripts and outcome for the client. DSS invited the SC Chair to identify stakeholders who will provide input into the study design. (Scheduled for Friday November 17 at 1:30 in LOB RM 3800).
o The Mercer contract ends March 31, 2007: there is some money under the current contract that can be used for the study; the remainder needs to be included in the next contract. This report would be available in spring 2007.
• If MCO data exists now can that be used to assess the extent of the problem with TS? DSS responded that the data is not in one system, would require manual edits, may over represent the scope of the problem if the prescribing practitioner agrees to the wait in providing the drug and would not answer the important question of the outcome of process for the client.
• Sheldon Toubman provided 2002-2003 data provided by Health Net under oath in discovery in the Karen L v. Health Net and DSS case showing that, for its entire Medicaid managed care population, there were about 3,000 rejections at the pharmacy each month for lack of prior authorization for a covered drug, and that about 2 to 3% of these rejections resulted in a TS of the drug being issued within 24 hours.
• The Bridgeport project funded by Robert Woods Johnson that included pharmacy education about the process was thought to resolve this issue.
• DSS will extrapolate information from the member handbooks to accompany any consumer survey about access to pharmacy.
DCF Review of pharmacy access
The DCF health advocates track health care access issues, including pharmacy, across payers for DCF children. This report looked at 93 cases over 3 months that came to the attention of the health advocate (not all issues get to the health advocate), of which 15 DCF children did not receive a script or the parent/guardian had to pay for the drug. Other denials were related to HUSKY coverage issues. Discussion raised questions about the pharmacy access issues for DCF children in spite of access to health advocates and S.Amdur suggested meeting with DCF to look at pharmacy tracking and eligibility issues.
Consumer Survey -Pharmacy Access
S. Amdur provided sample questions that could be used by DSS on a simple survey on medication access in HUSKY. DSS stated such a survey may not be able to determine the insurance payer at the time of the problem, confounding the results as they relate to HUSKY. While advocacy groups may want to survey their clients, DSS suggested that any client-based survey be considered as part of the DSS/Mercer study.
HUSKY Transportation for Medical/BH Services
Bridgeport consumers and providers have reported transportation issues that impact access to services.
• DSS has received complaints, some involving late pickups from EDT or arranging post-hospital discharge intensive services. DSS stated:
o They are meeting with VOI, MCOs and Logisticare vendor to identify transportation problems and fix them.
o DSS receives quarterly MCO transportation reports, as recommended by the SC and CTBHP/VOI also tracks problems that are addressed at the BHP meetings. VOI noted that the client “no show” rate for scheduled appointments is a problem for the family, the BH provider, the transportation vendor and program costs.
o The reports and outcome of the above meetings will be brought back to the SC.
Behavioral Health/Primary Care Integration Update
Judith Meyers (CHDI) had provided the SC with an overview of their efforts in coordination of BH and medical care in September. Dr. Schaefer (DSS) stated that the Enhanced Care Clinics will eventually be required to partner with primary care in their service area (in the current RFA this is voluntary). Some of the respondents to the ECC RFA provide adult services, so the sole focus will not just be on children. CHDI will host a bidders conference on Nov. 17th from 2-3:30 on the RFP for pediatric practices to partner with BH services. Contact CHDI @ 860-679-1519.
Judith Meyers will contact DMHAS regarding their plans for training PC providers on care integration that was funded in the SFY07 budget.