Prior Authorization Requests Research Articles

Impact of the Florida Medicaid Prior-Authorization Program on Use of Antipsychotics by Children Under Age Six

This study assessed the impact of a prior-authorization process on the use of antipsychotic medications by children under six years old in Florida's fee-for-service Medicaid program. Child psychiatrists reviewed requests for antipsychotic treatment (N=1,424) using forms and criteria created by a panel of Florida-based experts. Data on the characteristics of the children and clinicians involved were organized into 11 consecutive quarters beginning in July 2008. Multivariate generalized estimating equations were used to examine the association between each study variable and changes in the odds of submission of a new request over time. Prior-authorization requests declined from 124 in the first quarter to 81 in the last quarter. Compared with applications from child psychiatrists, the odds of applications being submitted by adult psychiatrists, neurologists, and pediatricians increased over time. Although applications declined, the diminished role of child psychiatry specialists raises questions about the impact of the program on the quality of care provided.

Modifying prescribing behaviour of angiotensin receptor blockers by selectively rescinding managerial prior authorization requirements for losartan

To evaluate whether rescinding the prior authorization (PA) requirement (managerial pre-approval) for losartan in an health maintenance organization (HMO) could reduce prescribing of the more expensive angiotensin receptor blockers (ARBs). HMO physicians were notified that losartan would no longer require PA, and appropriate changes were made to the electronic prescribing computer program. The monthly distribution by drug of the number of prescriptions for ARBs dispensed for new patients was calculated before and after the policy change from data captured from electronic records. The proportion of patients (percentage and 95% confidence interval) treated with losartan who met the criteria for treatment with ARBs (hypertension or cardiac insufficiency in patients who have developed adverse effects in response to angiotensin-converting enzyme inhibitors or macroproteinuria) during the first month after the PA requirement was rescinded was calculated. The total number of PA requests for ARBs declined by 48.6% from 961 in December 2008, the month before the policy change, to 494 the following January, rising again to 651 during January 2010. Prescription incidence changed from 121 to 255 patients treated per month (114% increase) for losartan, from 15 to 16 (6.7% increase) for candesartan, and from 89 to 71 (20.2% decrease) for valsartan. The duration of effect for decrease in ARB requests for the more expensive drugs was approximately 1 year. Only 23.3% (95% confidence interval 18.1-28.4) of patients receiving losartan met the criteria for receiving ARBs. Rescinding the PA requirement for this drug alone was an effective limited-duration strategy for reduction of prescription of relatively expensive drugs.

Physician Frustrations and the �Economics� of Growth Hormone Therapy Prior-Authorization Requests and Their Denial by Insurance Payers

Growth hormone has been approved by the Food and Drug Administration (FDA) for treating short children with growth failure due to a variety of causes, including growth hormone deficiency (GHD), Turner Syndrome, Prader-Willi Syndrome, idiopathic short stature (ISS), chronic renal insufficiency and children born small for gestational age (SGA) with inadequate growth by their second birthday. Children with GHD tend to be the largest proportion of short children with growth failure. Growth hormone has a very short half-life in serum with a pulsatile pattern of release, like most pituitary hormones. A random blood draw for growth hormone is thus impractical as a means of diagnosing GHD. The diagnosis of GHD must be established usually by performing a growth hormone stimulation test. This is done by ‘provocation’ with pharmacological agents that cause the anterior pituitary to release stored growth hormone. The conventional cut off for diagnosing GHD under testing conditions is currently 5 micrograms/dL for adults and 10 micrograms/dL for children. Generally, growing children secrete higher levels of growth hormone than do adults, and thus would have higher serum levels under physiological conditions. Endocrinologists utilize various agents for the provocative tests; these include arginine, levodopa, clonidine, glucagon and insulin. Insulin is considered the ‘gold standard’ for growth hormone provocation tests though it is the least utilized, because of the associated danger of hypoglycemia and the need for the presence of qualified staff throughout the testing procedure to monitor and prevent such a complication.

Effects of Prior Authorization on Medication Discontinuation Among Medicaid Beneficiaries With Bipolar Disorder

Few data exist on the cost and quality effects of increased use of prior-authorization policies to control psychoactive drug spending among persons with serious mental illness. This study examined the impact of a prior-authorization policy in Maine on second-generation antipsychotic and anticonvulsant utilization, discontinuations in therapy, and pharmacy costs among Medicaid beneficiaries with bipolar disorder. Using Medicaid and Medicare utilization data for 2001-2004, the authors identified 5,336 patients with bipolar disorder in Maine (study state) and 1,376 in New Hampshire (comparison state). With an interrupted time-series and comparison group design, longitudinal changes were measured in second-generation antipsychotic and anticonvulsant use; survival analysis was used to examine treatment discontinuations and rates of switching medications. The prior-authorization policy resulted in an 8-percentage point reduction in the prevalence of use of nonpreferred second-generation antipsychotic and anticonvulsant medications (those requiring prior authorization) but did not increase use of preferred agents (no prior authorization) or rates of switching. The prior-authorization policy reduced total pharmacy reimbursements for bipolar disorder by $27 per patient during the eight-month policy period. However, the hazard rate of treatment discontinuation (all bipolar drugs) while the policy was in effect was 2.28 (95% confidence interval=1.36-4.33) higher than during the prepolicy period, with adjustment for trends in the comparison state. The small reduction in pharmacy spending for bipolar treatment after the policy was implemented may have resulted from higher rates of medication discontinuation rather than switching. The findings indicate that the prior-authorization policy in Maine may have increased patient risk without appreciable cost savings to the state.

Prior Authorization of Newer Insomnia Medications in Managed Care: Is It Cost Saving?

New pharmacotherapeutic treatment options are available to treat patients with 1 or more insomnia symptoms. However, these new pharmaceuticals are subject to a variety of managed-care tools, such as prior authorizations, that may restrict access to these medications. The objective of this study was to evaluate the economic consequences to a health plan that requires prior authorization for nonbenzodiazepine medications approved for the treatment of insomnia characterized by difficulties both falling and staying asleep. An economic model was constructed to determine the effects of a typical prior-authorization program across a hypothetical managed-care population. Model parameters were derived from national estimates and a literature review. Economic consequences of a prior-authorization program were based on a hypothetical managed-care plan with 500,000 insured patients. An estimated acquisition cost of $300 per 100 tablets of medication requiring prior authorization, $40 to process each priorauthorization request, and prior-authorization rejection rates of 2% to 5% were considered. Using the default-model inputs of the hypothetical plan characteristics and costs, the economic model estimated a loss of $600,000 to $700,000 per year to the health plan. In a 3-way threshold sensitivity analysis when prior-authorization rejection rate was increased to 5%, the cost of each request in the prior-authorization program was decreased to $20, and the cost of a first-generation nonbenzodiazepine was decreased to a generic price (i.e. $100 per prescription), the model continued to show a net loss to managed care in each case. This model showed that requiring prior authorization for newer sleep treatments might not be a cost-saving strategy for managed-care organizations.

Evaluating The Therapeutic Package for Diabetic Patients: The Whole Exceeds the Sum of Its Parts

A s health professionals treat patients under the Medicare Modernization Act, subtle but important changes in the experience of designing drug treatments for diabetes and related disorders are becoming apparent. The first change to affect providers is a clear rise in the frequency of requests for “prior authorization” of nonformulary prescription agents. This increase was a predicted effect of Medicare D, and its impact on physician work patterns and the costs of rendering care to diabetic patients is not at all welcome.1 The increase in prior-authorization requests may also reflect a greater consumer awareness of insurance coverage for drugs and greater resistance to obtain drugs that are costly but not covered by insurance plans. As physicians are, in some way or another, profiled about the outcomes of the diabetes care they render (“pay-for-performance”), changes in physician prescribing behavior are predicted.2,3 All of the recent and coming influences on providers and patients alike may lead to essential alterations in how both physicians and consumers view drugs that are prescribed for the treatment of individual patients. The composite effects of these trends on prescribing behavior have not been fully assessed. However, there are many reasons to suggest that profound changes may be imminent in how physicians, patients, and pharmaceutical vendors interact over the selection of pharmacological agents and medical devices in the care of diabetic patients. Given the profound impact we are already seeing in the numbers of prior-authorization requests under Medicare D as an index of these coming changes, an assessment of these possible trends may be helpful to diabetes care providers. Experienced physicians know well what has not been clearly stated in the literature until recently: that the customary decision-making processes that are typically used to select treatments for diabetes and the influences used to encourage …

Analysis of a prescription drug prior authorization program in a Medicaid health maintenance organization.

To determine the factors important in approving prescription reimbursement under prior authorization (PA) in a Medicaid managed care organization (MCO). A cross-sectional statistical analysis was performed using administrative data for one month of PA requests to an MCO with more than 250,000 Medicaid recipients in the northeast United States. More than 95% of PA reviews resulted in payment for the originally prescribed products. The most common treatments involved were atypical antipsychotics, antacids, antidepressants, antihypertensives, anticonvulsants, and Cox-2 inhibitors. The rejection rate for nonformulary products was 7.1% while that for formulary products was 3.7%. Nevertheless, most drugs requiring PA were formulary- listed, with protocols to reinforce prescription guidelines. Rejection of reimbursement was inversely related to patient age. Most likely to be authorized were drugs for smoking cessation, pain, and nausea, while those least likely to be approved were multivitamins, sleep aids, and high-cost antidepressants. Although nonformulary products are more frequently subject to PA, 78.6% of PA procedures are performed in response to requests for formulary-listed products. The PA rejection rate for this Medicaid MCO was small; 4.4% overall and 7.1% for nonformulary versus 3.7% for formulary drugs.

Evaluating the Operational Performance and Financial Effects of a Drug Prior Authorization Program

OBJECTIVE: To present a managerial approach for evaluating the performance of a drug prior authorization (PA) program, illustrated through an evaluation of the Iowa Medicaid drug PA program. DESIGN: A before-and-after comparison without a control group. SETTING: State of Iowa Medicaid Program. PATIENTS: Iowa Medicaid enrollees (approximately 250,000). INTERVENTION: Medicaid Drug Prior Authorization (PA) Program. MAIN OUTCOME MEASURES: Operational and economic performance, including volume of prior authorization requests, PA program response times, PA approval rates by therapeutic category, medication utilization, and PA program savings and administrative costs. RESULTS: Overall, 82.9% of new and extension PA requests were approved for coverage. Of the new PA requests, 74.4% were approved for coverage, while 92.5% of PA extensions were approved. The average response time for new requests and extensions was 52.4 (s.d.=1 01.8) minutes. New PA responses averaged 73.2 (s.d.=119.6) minutes, while extensions averaged 28 (s.d.=7.5) minutes. The total net savings for antiarthritics, benzodiazepines, antiulcer, and antihistamines was $2.51 million to $3.83 million. CONCLUSION: The results are unique in providing both operational and economic performance of a drug PA program. The results show response times well below the HCFA mandated guidelines with relatively high approval rates. The economic results also suggest a large savings due to drug prior authorization. The evaluation procedures provide a workable method for program administrators to evaluate their own programs. In addition, the results provide a comparison for program administrators to judge performance.