26-18-103 - DUR Board -- Responsibilities.
26-18-103. DUR Board -- Responsibilities.
The board shall:
(1) develop rules necessary to carry out its responsibilities as defined in this part;
(2) oversee the implementation of a Medicaid retrospective and prospective DURprogram in accordance with this part, including responsibility for approving provisions ofcontractual agreements between the Medicaid program and any other entity that will process andreview Medicaid drug claims and profiles for the DUR program in accordance with this part;
(3) develop and apply predetermined criteria and standards to be used in retrospectiveand prospective DUR, ensuring that the criteria and standards are based on the compendia, andthat they are developed with professional input, in a consensus fashion, with provisions fortimely revision and assessment as necessary. The DUR standards developed by the board shallreflect the local practices of physicians in order to monitor:
(a) therapeutic appropriateness;
(b) overutilization or underutilization;
(c) therapeutic duplication;
(d) drug-disease contraindications;
(e) drug-drug interactions;
(f) incorrect drug dosage or duration of drug treatment; and
(g) clinical abuse and misuse;
(4) develop, select, apply, and assess interventions and remedial strategies for physicians,pharmacists, and recipients that are educational and not punitive in nature, in order to improvethe quality of care;
(5) disseminate information to physicians and pharmacists to ensure that they are awareof the board's duties and powers;
(6) provide written, oral, or electronic reminders of patient-specific or drug-specificinformation, designed to ensure recipient, physician, and pharmacist confidentiality, and suggestchanges in prescribing or dispensing practices designed to improve the quality of care;
(7) utilize face-to-face discussions between experts in drug therapy and the prescriber orpharmacist who has been targeted for educational intervention;
(8) conduct intensified reviews or monitoring of selected prescribers or pharmacists;
(9) create an educational program using data provided through DUR to provide activeand ongoing educational outreach programs to improve prescribing and dispensing practices,either directly or by contract with other governmental or private entities;
(10) provide a timely evaluation of intervention to determine if those interventions haveimproved the quality of care;
(11) publish an annual report, subject to public comment prior to its issuance, and submitthat report to the United States Department of Health and Human Services by December 1 ofeach year. That report shall also be submitted to legislative leadership, the executive director, thepresident of the Utah Pharmaceutical Association, and the president of the Utah MedicalAssociation by December 1 of each year. The report shall include:
(a) an overview of the activities of the board and the DUR program;
(b) a description of interventions used and their effectiveness, specifying whether theintervention was a result of underutilization or overutilization of drugs, without disclosing theidentities of individual physicians, pharmacists, or recipients;
(c) the costs of administering the DUR program;
(d) any fiscal savings resulting from the DUR program;
(e) an overview of the fiscal impact of the DUR program to other areas of the Medicaidprogram such as hospitalization or long-term care costs;
(f) a quantifiable assessment of whether DUR has improved the recipient's quality ofcare;
(g) a review of the total number of prescriptions, by drug therapeutic class;
(h) an assessment of the impact of educational programs or interventions on prescribingor dispensing practices; and
(i) recommendations for DUR program improvement;
(12) develop a working agreement with related boards or agencies, including the StateBoard of Pharmacy, Physicians' Licensing Board, and SURS staff within the division, in order toclarify areas of responsibility for each, where those areas may overlap;
(13) establish a grievance process for physicians and pharmacists under this part, inaccordance with Title 63G, Chapter 4, Administrative Procedures Act;
(14) publish and disseminate educational information to physicians and pharmacistsconcerning the board and the DUR program, including information regarding:
(a) identification and reduction of the frequency of patterns of fraud, abuse, grossoveruse, inappropriate, or medically unnecessary care among physicians, pharmacists, andrecipients;
(b) potential or actual severe or adverse reactions to drugs;
(c) therapeutic appropriateness;
(d) overutilization or underutilization;
(e) appropriate use of generics;
(f) therapeutic duplication;
(g) drug-disease contraindications;
(h) drug-drug interactions;
(i) incorrect drug dosage and duration of drug treatment;
(j) drug allergy interactions; and
(k) clinical abuse and misuse;
(15) develop and publish, with the input of the State Board of Pharmacy, guidelines andstandards to be used by pharmacists in counseling Medicaid recipients in accordance with thispart. The guidelines shall ensure that the recipient may refuse counseling and that the refusal isto be documented by the pharmacist. Items to be discussed as part of that counseling include:
(a) the name and description of the medication;
(b) administration, form, and duration of therapy;
(c) special directions and precautions for use;
(d) common severe side effects or interactions, and therapeutic interactions, and how toavoid those occurrences;
(e) techniques for self-monitoring drug therapy;
(f) proper storage;
(g) prescription refill information; and
(h) action to be taken in the event of a missed dose; and
(16) establish procedures in cooperation with the State Board of Pharmacy forpharmacists to record information to be collected under this part. The recorded information shallinclude:
(a) the name, address, age, and gender of the recipient;
(b) individual history of the recipient where significant, including disease state, knownallergies and drug reactions, and a comprehensive list of medications and relevant devices;
(c) the pharmacist's comments on the individual's drug therapy;
(d) name of prescriber; and
(e) name of drug, dose, duration of therapy, and directions for use.
Amended by Chapter 382, 2008 General Session