Article

Effects of a prior-authorization policy for celecoxib on medical service and prescription drug use in a managed care Medicaid population.

Oregon State University College of Pharmacy, Portland, USA.
Clinical Therapeutics (impact factor: 2.32). 09/2004; 26(9):1518-32. DOI:10.1016/j.clinthera.2004.09.013 pp.1518-32
Source: PubMed

ABSTRACT Prior authorization (PA) is a poorly studied but commonly employed policy used by health care payers to manage the rising costs of pharmacy benefits.
The aim of this study was to evaluate the intended and unintended effects of a PA policy for celecoxib on pharmacy and medical-service utilization in a Medicaid managed-care organization.
This was a retrospective, interrupted time-series analysis of 22 monthly health-related utilization rates from January 1, 1999, to October 31, 2000. All Medicaid claims for CareOregon (a managed-care organization) and a fee-for-service program were reviewed. A model was constructed to evaluate changes in utilization of therapeutically related drug classes (eg, conventional nonsteroidal anti-inflammatory drugs [NSAIDs], gastrointestinal agents), office and emergency-department encounters, and hospitalizations before and after the PA policy was implemented on November 16, 1999. A secondary analysis evaluated these changes among a sample of prior NSAID users.
After the PA policy was implemented, use of celecoxib was immediately reduced from 1.07 to 0.53 days' supply per person-year (58.9%; 95% CI, 50.0%-67.9%). The monthly rate of increase was also reduced (P < 0.001). Utilization changes were not observed in other drug classes. Similar changes were observed in the secondary analysis. An 18% (95% CI, 2.2%-33.9%) nonsignificant increase in emergency-department visits was observed in the entire sample after the PA policy was implemented. However, a similar change was not observed in the secondary analysis of prior NSAID users. No other changes in medical service encounters were noted after the PA policy was activated.
This observational study found that celecoxib use was substantially reduced after the implementation of a PA policy. No important changes in use of other drug classes were detected. The overall increase in emergency-department visits--although not observed among previous NSAID users--should be explored on the individual level.

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    Article: The impact of nonreferral outpatient co-payment on medical care utilization and expenditures in Taiwan.
    Li-Chia Chen, Ellen I Schafheutle, Peter R Noyce
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    ABSTRACT: Taiwan's National Health Insurance's (NHI) generous coverage and patients' freedom to access different tiers of medical facilities have resulted in accelerating outpatient care utilization and costs. To deter nonessential visits and encourage initial contact in primary care (physician clinics), a differential co-payment was introduced on 15th July 2005. Under this, patients pay more for outpatient consultations at "higher tiers" of medical facilities (local community hospitals, regional hospitals, medical centers), particularly if accessed without referral. This study explored the impact of this policy on outpatient medical activities and expenditures, different co-payment groups, and tiers of medical facilities. A segmented time-series analysis on regional weekly outpatient medical claims (January 2004 to July 2006) was conducted. Outcome variables (number of visits, number of outpatients, total cost of outpatient care) and variables for cost structure were stratified by tiers of medical facilities and co-payment groups. Analysis used the auto-regressive integrated moving-average model in STATA 9.0. The overall number of outpatient visits significantly decreased after policy implementation due to a reduction in the number of patients using outpatient facilities, but total costs of care remained unchanged. The policy had its greatest impact on the number of visits to regional and local community hospitals but had no influence on those to the medical centers. Medical utilization in physician clinics decreased due to an audit of reimbursement declarations. Overall, the policy failed to encourage referrals from primary care to higher tiers because there was no obvious shifting of medical utilization and costs reversely. Differential co-payment policy decreased total medication utilization but not costs to NHI. The results suggest that the increased level of co-payment charge and the strategy of a single cost-sharing policy are not sufficient to promote referrals within the system. To achieve an effective co-payment policy, further research is needed to explore how patients' out-of-pocket payment affects medical utilization and which forces (not susceptible to co-payment) act in tertiary facilities.
    Research in Social and Administrative Pharmacy 10/2009; 5(3):211-24. · 2.35 Impact Factor
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Keywords

22 monthly health-related utilization rates
 
conventional nonsteroidal anti-inflammatory drugs [NSAIDs]
 
emergency-department encounters
 
emergency-department visits
 
entire sample
 
fee-for-service program
 
health care payers
 
individual level
 
January 1
 
managed-care organization
 
Medicaid claims
 
Medicaid managed-care organization
 
medical service encounters
 
medical-service utilization
 
October 31
 
PA policy
 
pharmacy benefits
 
prior NSAID users
 
secondary analysis
 
time-series analysis