Checking In With CMH
The Drop-off in Antipsychotic Prescribing in Philadelphia Medicaid
By Molly Candon, PhD and Oluwatoyin Fadeyibi, PharmD, MPH
Between 2014 and 2018 in Philadelphia, the number of children with Medicaid who received an antipsychotic prescription fell by nearly 50%, as we described recently in BMC Psychiatry. The reduction was larger for children who were less than 10 years old and for youth enrolled in foster care, the latter of whom have historically higher rates of antipsychotic prescribing.
The drop-off in antipsychotic prescribing in Philadelphia Medicaid is likely attributable to several factors. Philadelphia started requiring providers to get prior authorization (i.e., pre-approval) before prescribing antipsychotics to children, which may explain our finding of a disproportionate decline in prescribing to youth who were less than 10 years old. And the larger-than-average reduction among foster-care enrolled youth may be attributable to Pennsylvania’s efforts to improve quality of care for this group, which came after joint work between the Pennsylvania Department of Human Services and CHOP’s PolicyLab.
While reduced antipsychotic prescribing is a welcome change given concerns about the risks associated with antipsychotic use, including metabolic and movement disorders, the overall rate of antipsychotic prescribing is only part of the story. Understanding how antipsychotics are used in a broader treatment regimen is also critical. Community Behavioral Health (CBH), the sole behavioral health managed care organization serving Philadelphia Medicaid enrollees, is engaged in various efforts to ensure that antipsychotic prescriptions are used as part of an evidence-based care plan, which often includes psychosocial support and medication management. In fact, the trends detailed in our recent article were drawn from preliminary data supporting the introduction of antipsychotic prescribing report cards, which CBH sent to local providers in early 2021 to encourage judicious prescribing. The customized prescribing report cards included peer comparison rankings of antipsychotic prescribing and other measures related to the quality of care, including the share of youth who received proper medication management (e.g., metabolic panels) and the share of youth who received other school- and community-based psychosocial support.
While reduced antipsychotic prescribing is a welcome change given concerns about the risks associated with antipsychotic use, including metabolic and movement disorders, the overall rate of antipsychotic prescribing is only part of the story.
The prescribing report cards also informed providers of the share of their patients who received an antipsychotic prescription for an unapproved indication, which accounted for half of antipsychotic prescriptions in both 2014 and 2018 (approved indications for the Philadelphia Medicaid population include autism, bipolar disorder, psychosis, and conduct disorders). We are learning more about why antipsychotic prescriptions are used for these indications, but our study did shed light on how they are being used. For example, we found that the length of an antipsychotic prescription for unapproved indications was shorter on average than the prescription length for approved indications. This suggests that providers take a more cautious approach when prescribing antipsychotics for unapproved indications.
While our study had some limitations, including a focus on a single population that may not be representative of other populations, our results have important implications. We found that children in Philadelphia Medicaid are experiencing a dramatic drop-off in antipsychotic prescribing, which suggests that the various policy and practice interventions that target antipsychotic prescribing are effective. More research is needed to understand whether these trends reflect more appropriate antipsychotic prescribing, as the goal of the antipsychotic prescribing report cards was not to reduce prescribing per se, but rather to increase the quality of care for Medicaid-enrolled youth with an antipsychotic prescription.
Figure 1. Number of Medicaid-enrolled Youth with an Antipsychotic Prescription for Any Indication and an Antipsychotic Prescription for Unapproved Indications