Effects of a prior-authorization policy for celecoxib on medical service and prescription drug use in a managed care Medicaid population.
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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ABSTRACT: Determine the impact of a Prior Authorization Requirement (PAR) program on Medicaid pharmacy expenditures and utilization. Prescription claims for Nebraska Medicaid recipients who received a cyclooxygenase-2 (COX-2) inhibitor, a nonselective nonsteroidal antiinflammatory (NSAID) drug, or other pain relievers between July 2001 and June 2003. STUDY DESIGN AND DATA COLLECTION/EXTRACTION: This was a retrospective cross-sectional study with a 12-month pre-PAR implementation period and a 12-month post-PAR implementation period. Pharmacy transactions for COX-2 inhibitors, NSAIDs, other pain relievers, and gastroprotectants were identified by their National Drug Code (NDC) in a Microsoft SQL query. The PAR was designed to approve COX-2 inhibitor use only for recipients at high risk of GI side effects while restricting access to those patients at low to moderate risk of GI side effects. One year following implementation of the PAR, overall expenditures on COX-2 inhibitors for Nebraska Medicaid dropped 50 percent. The overall impact on pharmacy expenditures, including NSAIDs, pain relief medications, and gastroprotectants when necessary to relieve gastrointestinal (GI) side effects, for those recipients who switched from a COX-2 inhibitor to an NSAID or other pain relievers was a decline of approximately 35 percent. CONCLUSION AND IMPLICATIONS FOR STATE POLICY: PAR for COX-2 inhibitors successfully reduced Medicaid prescription expenditures. Recipients at high risk for GI side effects appropriately received COX-2 inhibitors. Recipients at low to moderate risk for GI side effects who were switched to NSAIDs or other pain relievers had lower overall prescription expenditures. Further research is needed to determine the impact of PAR on overall health outcomes and costs. In this study, rather than take a "one size fits all" approach to prescription drug cost-saving strategies, Medicaid policy makers understood that patient variation required accurate identification of disease severity to determine when equally efficacious low-cost alternatives were appropriate.Health Services Research 03/2008; 43(1 Pt 2):435-50. DOI:10.1111/j.1475-6773.2007.00766.x · 2.49 Impact Factor
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ABSTRACT: Objective: To evaluate the effectiveness of an automated prior authorization (PA) system (SmartPA) in reducing use of and expen- ditures for cyclooxygenase-2 (COX-2) inhibitors. Study Design: Before and after with control group. Methods: After implementation of SmartPA in Missouri, changes in use of and expenditures for COX-2 inhibitors, COX-2 substitutes (traditional nonsteroidal anti-inflammatory drugs (NSAIDs) and other products for pain), and gastrointestinal (GI) protective agents were compared between the Medicaid program of Missouri and that of a state with no PA program for COX-2 inhibitors. Subjects were continuously enrolled for the 24-month study period and had a claim for a COX-2 inhibitor in the 12- month baseline period. Analyses included comparison of means and linear regression. Regressions controlled for age, sex, risk for GI complications, severity of illness, and the interaction between state and risk. Results: Changes in expenditures for COX-2 inhibitors, NSAIDs, other pain drugs, and GI-protective drugs were $256 higher, $56 lower, $21 higher, and $198 higher, respectively, in the control state among low-risk patients. Changes in expenditures were $102 higher, $12 lower, $21 lower, and $185 higher, respectively, in the control state among high-risk patients. Results were similar for drug utilization. Conclusion: Implementation of SmartPA resulted in reduced use of and expenditures for COX-2 inhibitors and reduced net expen- ditures for all pain and GI-protective medications. These effects were greatest for patients at low risk for GI complications. (Am J Manag Care. 2006;12:501-508)Value in Health 06/2005; 8(3):405-405. DOI:10.1016/S1098-3015(10)63102-6 · 2.89 Impact Factor
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ABSTRACT: Prior authorization has been used extensively as one of the mechanisms to control costs and ensure quality of care by the National Health Insurance (NHI) plan in Taiwan. An appeals system, the Dispute Mediation Committee (DMC), independent of the NHI, is available for interested parties to dispute denials of prior authorization. Currently, medications for Alzheimer's disease constitute the largest category of appeals. To describe the appeals system and analyze outcomes of cases of medications for Alzheimer's disease submitted to the Bureau of NHI (BNHI) for prior authorization and to the DMC for appeals. Prescriptions of donepezil and rivastigmine submitted for prior authorization from 2000 through 2002 were analyzed. Cases denied prior authorization and later submitted as appeals to the DMC were summarized with descriptive and bivariate methods. A total of 12,237 cases of donepezil and 6975 cases of rivastigmine were submitted to the BNHI for prior authorization; among them, 72.6% of donepezil and 66.5% of rivastigmine cases received authorization. Among the thousands of cases denied prior authorization, 124 appealed to the DMC for dispute resolution. The result of the majority of the appeals (111 [89.5%]) was to uphold the BNHI denial decision. Most of the appeals were denied because of the lack of appropriate exclusion of other possible causes of dementia. Most appeals were again denied after expert review. Better education concerning utilization guidelines and a platform for insurer, insuree, and physician to dialog are needed to improve the effectiveness and efficiency of the appeals system.Annals of Pharmacotherapy 04/2006; 40(3):506-11. DOI:10.1345/aph.1G437 · 2.92 Impact Factor