When gatekeepers meet the sentinel: the impact of a prior authorization requirement for cefuroxime on the prescribing behaviour of community-based physicians

Estimating the Practice-Level and National Cost Burden of Treatment-Related Prior Authorization for Academic Radiation Oncology Practices

PURPOSE

Prior authorization (PA) imposes significant time burdens on radiation oncology practices, but its financial impact has not been characterized. We used time-driven activity-based costing (TDABC) to assess the cost burden of treatment-related PA events at an academic radiation oncology practice. We then estimated annual costs for an academic practice and academic practices nationally.

METHODS AND MATERIALS

Using internal analyses, we created TDABC process maps for treatment-related PA events at an academic radiation oncology practice. Using published compensation data, internal workhour estimates, and supervisory requirements, we calculated the cost of each PA event and annual costs. Using data from the 2017 American Society for Radiation Oncology Workforce Survey and the 2018 American Society for Radiation Oncology Prior Authorization Survey, we estimated annual PA costs for academic medical centers nationally.

RESULTS

We successfully created TDABC process maps for treatment-related PA events at an academic radiation oncology practice. There were significant time and cost burdens for all events (range: 51-95 minutes, $28-$101 US dollars [USD]), with significant increases when peer-to-peer discussion was required (range: 92-95 minutes, $75-$101 USD). Annual treatment-related PA departmental costs were estimated to be $491,989 USD, with approved treatments accounting for the majority (94%; $463,027 USD). Nationally, annual treatment-related PA costs were estimated to be $40,125,848 USD, with approved treatments accounting for the majority (86%; $34,632,620 USD).

CONCLUSION

TDABC can be used to estimate the cost burden of PA events. These burdens are significant and translate into massive organizational costs. Our national estimates highlight the tremendous cost of PA for academic radiation oncology practices, with the majority of costs related to approved treatments.

Ethical Considerations for Equitable Access to Genomic Sequencing for Critically Ill Neonates in the United States

Rare diseases impact all socio-economic, geographic, and racial groups indiscriminately. Newborn screening (NBS) is an exemplary international public health initiative that identifies infants with rare conditions early in life to reduce morbidity and mortality. NBS theoretically promotes equity through universal access, regardless of financial ability. There is however heterogeneity in access to newborn screening and conditions that are screened throughout the world. In the United States and some other developed countries, NBS is provided to all babies, subsidized by the local or federal government. Although NBS is an equitable test, infants admitted to neonatal intensive care units (NICUs) may not receive similar benefits to healthier infants. Newborns in the NICU may receive delayed and/or multiple newborn screens due to known limitations in interpreting the results with prematurity, total parenteral nutrition, blood transfusions, infection, and life support. Thus, genomic technologies might be needed in addition to NBS for equitable care of this vulnerable population. Whole exome (WES) and genome sequencing (WGS) have been recently studied in critically ill newborns across the world and have shown promising results in shortening diagnostic odysseys and providing clinical utility. However, in certain circumstances several barriers might limit access to these tests. Here, we discuss some of the existing barriers to genomic sequencing in NICUs in the United States, explore the ethical implications related to low access, consider ways to increase access to genomic testing, and offer some suggestions for future research in these areas.

Impact of a health alert and its implementation on flutamide prescriptions for women: an interrupted time series analysis

BACKGROUND

Off-label drug use among ambulatory patients is often based on little or no scientific support. This paper reports the impact of a health warning about the risks of off-label flutamide use by women and the actions subsequently implemented by the public health service targeting such use.

METHOD

The study was undertaken in a region in north-west Spain. We designed a segmented regression model of an interrupted time series, in which the dependent variable was the monthly value of defined daily doses of flutamide per 1000 inhabitants/day (DDD/TID), both total and stratified by sex. The following two data sources were used: flutamide prescriptions billed to the Spanish National Health Service; and flutamide deliveries made by wholesale drug distributors to pharmacies. The intervention assessed consisted of the issue of an official health warning and the actions subsequently taken to implement it.

RESULTS

There was an immediate reduction of 49.33% in DDD/TID billed to the Spanish National Health Service in respect of women; the mean value of the population percentage of DDD/TID of flutamide billed in respect of women fell from 34.4% pre-intervention to 23.72% post-intervention. There was an immediate reduction of 19.92% (95%CI: 6.68-33.15%) in total DDD/TID invoiced. There were no significant changes in DDD/TID billed in respect of men or in flutamide use in the private medical sector.

CONCLUSIONS

Off-label drug misuse is a reality among ambulatory patients, even after actions are implemented following a toxicity warning issued by the competent Health Authority.

Impact of removal and restriction of me-too medicines in a hospital drug formulary on in- and outpatient drug prescriptions: interrupted time series design with comparison group

BACKGROUND

The study covered in- and out-of-hospital care in a region in north-western Spain. The intervention evaluated took the form of a change in the hospital drugs formulary. Before the intervention, the formulary contained four of the five low molecular weight heparins (LMWHs) marketed in Spain. The intervention consisted of withdrawing two LMWHs (bemiparin and dalteparin) from the formulary and restricting the use of another (tinzaparin), leaving only enoxaparin as an unrestricted prescription LMWH. Accordingly, the aim of this study was to evaluate the effect on in- and outpatient drug prescriptions of removing and restricting the use of several LMWHs in a hospital drugs formulary.

METHODS

We used a natural, before-after, quasi-experimental design with a control group and monthly data from January 2011 to December 2016. Based on data drawn from official Public Health Service sources, the following dependent variables were extracted: defined daily doses (DDD) per 1000 inhabitants per day (DDD/TID), DDD per 100 stays per day, and expenditure per DDD.

RESULTS

The two compounds that were removed from the formulary registered an immediate decrease at both an intra- and out-of-hospital level (66.6% and 55.6% for bemiparin and 73.0% and 92.2% for dalteparin, respectively); similarly, the compound that was restricted also registered an immediate decrease (36.1% and 9.0% at the in- and outpatient levels, respectively); in contrast, the remaining LMWH (enoxaparin) registered an immediate, significant increase at both levels (44.9% and 32.6%, respectively). The intervention led to an immediate reduction of 6.8% and a change in trend in out-of-hospital cost/DDD; it also avoided an expenditure of €477,317.1 in the 21 months following the intervention.

CONCLUSIONS

The results indicate that changes made in a hospital drugs formulary towards more efficient medications may lead to better use of pharmacotherapeutic resources in its health catchment area.

Trends in celecoxib and etoricoxib prescribing following removal of prior authorization requirement in Spain

WHAT IS KNOWN AND OBJECTIVE

Previous studies indicate that the implementation of a prior authorization requirement for coxibs was followed by a sharp decline in their use. There are no studies showing what happens if coxib prior authorization is removed. The objective of this study is to assess the trend in the use of coxibs marketed in Spain, following removal of their respective prior authorization requirements in November 2006 for celecoxib and February 2007 for etoricoxib.

METHODS

We calculated the monthly number of defined daily doses per thousand inhabitants per day (DDD/TID) of coxibs dispensed in a health area of Spain from mid-2005 to December 2007. Data were analysed both graphically and by means of a segmented regression model.

RESULTS AND DISCUSSION

At the start of the study period, use of coxibs showed no growth. At the date when prior authorization of celecoxib was removed (November 2006), however, DDD/TID of the coxib whose prior authorization had not been removed - namely etoricoxib - remained unchanged, whereas consumption of celecoxib increased significantly (by the end of the study period, celecoxib use displayed a relative increase of 615% in terms of the DDD/TID prescribed before the removal of its prior authorization requirement). Similarly, etoricoxib use remained unchanged until its prior authorization was removed (February 2007), from which time DDD/TID of etoricoxib also underwent a considerable increase (by the end of the study period, etoricoxib use displayed a relative increase of 793% in terms of the DDD/TID prescribed before the removal of its prior authorization). Segmented regression analysis showed a sharp, statistically significant rise and change in slope in both celecoxib and etoricoxib use immediately after removal of their respective prior authorizations.

WHAT IS NEW AND CONCLUSION

Use of celecoxib and etoricoxib rose sharply after removal of their respective prior authorizations.

Empiric Treatment of Uncomplicated Urinary Tract Infection with Fluoroquinolones in Older Women in Israel: Another Lost Treatment Option?

Background:

Current guidelines for the treatment of uncomplicated urinary tract infection (UTI) in women recommend empiric therapy with antibiotics for which local resistance rates do not exceed 10–20%. We hypothesized that resistance rates of Escherichia coli to fluoroquinolones may have surpassed this level in older women in the Israeli community setting.

Objectives:

To identify age groups of women in which fluoroquinolones may no longer be appropriate for empiric treatment of UTI.

Methods:

Resistance rates for ofloxacin were calculated for all cases of uncomplicated UTI diagnosed during the first 5 months of 2005 in a managed care organization (MCO) in Israel, in community-dwelling women aged 41–75 years. The women were without risk factors for fluoroquinolone resistance. Uncomplicated UTI was diagnosed with a urine culture positive for E. coli. The data set was stratified for age, using 5 year intervals, and stratum-specific resistance rates (% and 95% CI) were calculated. These data were analyzed to identify age groups in which resistance rates have surpassed 10%.

Results:

The data from 1291 urine cultures were included. The crude resistance rate to ofloxacin was 8.7% (95% CI 7.4 to 10.2). Resistance was lowest among the youngest (aged 41–50 y) women (3.2%; 95% CI 1.11 to 5.18), approached 10% in women aged 51–55 years (7.1%; 95% CI 3.4 to 10.9), and reached 19.86% (95% CI 13.2 to 26.5) among the oldest women (aged 56–75 y).

Conclusions:

Physicians who opt to treat UTI in postmenopausal women empirically should consider prescribing drugs other than fluoroquinolones. Concomitant longitudinal surveillance of both antibiotic utilization patterns and uropathogen resistance rates should become routine practice in this managed-care organization.

Revealed Opportunism: How Physicians "Game" Prior Authorization Protocols Until They Are Rescinded

BACKGROUND

Prior authorization (PA) is a management technique that has been implemented to manage the utilization of expensive drugs and to improve the precision of drug prescribing. PA requirements may incentivize physicians to document adverse effects, sometimes falsely, to meet the eligibility requirements.

OBJECTIVES

To identify documentation patterns that may facilitate the quantitative analysis of physician gaming and underreporting behaviors associated with the prescribing of angiotensin-converting enzyme (ACE) inhibitors in a primary care setting, and to evaluate the effect of a PA requirement on the documentation of adverse events as a way to receive approval for more expensive drugs.

METHODS

We conducted a retrospective analysis of physician electronic reporting of adverse effects associated with ACE inhibitors before and after the revocation of a PA requirement for angiotensin receptor blockers (ARBs) between 2004 and 2013 in an Israeli HMO. The data were stratified into 2 groups-patients who were newly prescribed an ACE inhibitor or those who had been receiving an ACE inhibitor for at least 1 year. The annual rate of adverse events related to ACE inhibitors (ie, the number of reported cases of adverse events per 1000 patients receiving an ACE inhibitor) was calculated from data captured on the date the events were first reported for the 5 years before and 5 years after the revocation of the PA constraint.

RESULTS

A total of 151,845 patients treated with ACE inhibitors were identified during the 10-year study period. The reported adverse events among patients newly treated with an ACE inhibitor peaked in 2007 to 10 cases per 1000 patients, and gradually decreased to 4.6 cases in 2012, which was the year after the PA requirements for the ARBs valsartan and candesartan were rescinded by the HMO. Among previously treated patients, adverse events rates decreased from a high of 5.4 per 1000 patients in 2008 to 1.9 in 1000 patients in 2012, the year after the PA restraints for the last 2 ARBs with a requirement were revoked.

CONCLUSIONS

The PA requirement influenced physician propensity for reporting drug side effects, possibly encouraging reporting inaccuracies. The decline in the incidence of reported side effects, in both subpopulations in the study, with the revocation of the PA requirement confirms our hypothesis that physicians were incentivized to document the side effects related to ACE inhibitors to meet the eligibility requirements for the approval of an ARB by the HMO.

Practice characteristics and prior authorization costs: secondary analysis of data collected by SALT-Net in 9 central New York primary care practices

Background

An increase in prior authorization (PA) requirements from health insurance companies is placing administrative and financial burdens on primary care offices across the United States. As time allocation for these cases continues to grow, physicians are concerned with additional workload and inefficiency in the workplace. The objective is to estimate the effects of practice characteristics on time spent per prior authorization request in primary care practices.

Methods

Secondary analysis was performed using data on nine primary care practices in Central New York. Practice characteristics and demographics were collected at the onset of the study. In addition, participants were instructed to complete an "event form" (EF) to document each prior authorization event during a 4–6 week period; prior authorizations included requests for medication as well as other health care services. Stepwise Ordinary Least Squares (OLS) Regression was used to model Time in Minutes of each event as an outcome of various factors.

Results

Prior authorization events (N = 435) took roughly 20 minutes to complete (beta = 20.017, p < .001); Medicaid requests took less time (beta = −6.085, p < .001), and Electronic Health Record (EHR) system use reduced prior authorization time by about 5 minutes (beta = −5.086, p = .002).

Conclusions

While prior authorization events impose substantial costs to primary care offices, it appears that Medicaid requests take less time than private payer requests. Results from the study provide support that Electronic Health Record usage may also reduce time required to complete prior authorization requests.

Evaluating the impact of a novel restricted reimbursement policy for quinolone antibiotics: a time series analysis

BACKGROUND

Publicly-funded drug plans often use prior authorization policies to limit drug prescribing. To guide physician prescribing of a class of antibiotics with broad antimicrobial activity (quinolone antibiotics) in accordance with new prescribing guidelines, Alberta's provincial health ministry implemented a new mechanism for formulary restriction entitled the optional special authorization (OSA) program. We conducted an observational study to determine the impact of this new formulary restriction policy on antimicrobial prescription rates as well as any clinical consequences.

METHODS

Quinolone antibiotic use, and adherence with quinolone prescribing guidelines, was assessed before and after implementation of the OSA program in patients with common outpatient infections using an administrative data cohort and a chart review cohort, respectively. At the same time this policy was implemented to limit quinolone prescribing, two new quinolone antibiotics were added to the formulary. Using administrative data, we analysed a total of 397,534 unique index visits with regard to overall antibiotic utilization, and through chart review, we analysed 1681 charts of patients with infections of interest to determine the indications for quinolone usage.

RESULTS

Using segmented regression models adjusting for age, sex and physician enrollment in the OSA program, there was no statistically significant change in the monthly rate of all quinolone use (-3.5 (95% CI -5.5, 1.4) prescriptions per 1000 index visits) following implementation of the OSA program (p = 0.74). There was a significant level change in the rate of quinolone antibiotic use for urinary tract infection (-33.6 (95% CI: -23.8, -43.4) prescriptions and upper respiratory tract infection (-16.1 (95%CI: -11.6, -20.6) prescriptions per 1000 index visits. Among quinolone prescriptions identified on chart review, 42.5% and 58.5% were consistent with formulary guidelines before and after the implementation of the OSA program, respectively (p = 0.002). There was no change in hospitalization, mortality or use of physician services after implementation of the OSA program.

CONCLUSIONS

Despite the addition of two new quinolone antibiotics to the formulary, we found that there was no change in the use of quinolones after implementation of a new formulary restriction policy for outpatients with common outpatient infections.

Pharmaceutical policies: effects of restrictions on reimbursement

BACKGROUND

Public policy makers and benefit plan managers need to restrain rising pharmaceutical drug costs while preserving access and optimizing health benefits.

OBJECTIVES

To determine the effects of a pharmaceutical policy restricting the reimbursement of selected medications on drug use, health care utilization, health outcomes and costs (expenditures).

SEARCH STRATEGY

We searched the 14 major bibliographic databases and websites (to January 2009).

SELECTION CRITERIA

Included were studies of pharmaceutical policies that restrict coverage and reimbursement of selected drugs or drug classes, often using additional patient specific information related to health status or need. We included randomised controlled trials, non-randomised controlled trials, interrupted time series (ITS) analyses, repeated measures studies and controlled before-after studies set in large care systems or jurisdictions.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study limitations. Quantitative re-analysis of time series data was undertaken for studies with sufficient data.

MAIN RESULTS

We included 29 ITS analyses (12 were controlled) investigating policies targeting 11 drug classes for restriction. Participants were most often senior citizens or low income adult populations, or both, in publically subsidized or administered pharmaceutical benefit plans. Impact of policies varied by drug class and whether restrictions were implemented or relaxed. When policies targeted gastric-acid suppressant and non-steroidal anti-inflammatory drug classes, decreased drug use and substantial savings on drugs occurred immediately and for up to two years afterwards, with no increase in the use of other health services (6 studies). Targeting second generation antipsychotic drugs increased treatment discontinuity and the use of other health services without reducing overall drug expenditures (2 studies). Relaxing restrictions for reimbursement of antihypertensives and statins increased appropriate use and decreased overall drug expenditures. Two studies which measured health outcomes directly were inconclusive.

AUTHORS' CONCLUSIONS

Implementing restrictions to coverage and reimbursement of selected medications can decrease third-party drug spending without increasing the use of other health services (6 studies). Relaxing reimbursement rules for drugs used for secondary prevention can also remove barriers to access. Policy design, however, needs to be based on research quantifying the harm and benefit profiles of target and alternative drugs to avoid unwanted health system and health effects. Health impact evaluation should be conducted where drugs are not interchangeable. Impacts on health equity, relating to the fair and just distribution of health benefits in society (sustainable access to publically financed drug benefits for seniors and low income populations, for example), also require explicit measurement.

The tools of an evidence-based culture: implementing clinical-practice guidelines in an Israeli HMO

PURPOSE

Although clinical-practice guidelines (CPGs) are implemented on the assumption that they will improve the quality, efficiency, and consistency of health care, they generally have limited effect in changing physicians' behavior. The purpose of this study was to design and implement an effective program for formulating, promulgating, and implementing CPGs to foster the development of an evidence-based culture in an Israeli HMO.

METHOD

The authors implemented a four-stage program of stepwise collaborative efforts with academic institutions composed of developing quantitative tools to evaluate prescribing patterns, updating CPGs, collecting MDs' input via focus groups and quantitative surveys, and conducting a randomized controlled trial of a two-stage, multipronged intervention. The test case for this study was the development, dissemination, and implementation of CPG for the treatment of acute uncomplicated cystitis in adult women. Interventions in the form of a lecture at a conference and a letter with personalized feedback were implemented, both individually and combined, to improve physicians' rates of prescribing the first-line drug, nitrofurantoin, and, in the absence of nitrofurantoin, adhering to the recommended duration of three days of treatment with ofloxacin.

RESULTS

The tools and data-generating capabilities designed and constructed in Stage I of the project were integral components of all subsequent stages of the program. Personalized feedback alone was sufficient to improve the rate of adherence to the guidelines by 19.4% (95% CI = 16.7, 22.1).

CONCLUSIONS

This study provides a template for introducing the component of experimentation essential for cultivating an evidence-based culture. This process, composed of collaborative efforts between academic institutions and a managed care organization, may be beneficial to other health care systems.

Prescription drug cost sharing: associations with medication and medical utilization and spending and health

CONTEXT

Prescription drugs are instrumental to managing and preventing chronic disease. Recent changes in US prescription drug cost sharing could affect access to them.

OBJECTIVE

To synthesize published evidence on the associations among cost-sharing features of prescription drug benefits and use of prescription drugs, use of nonpharmaceutical services, and health outcomes.

DATA SOURCES

We searched PubMed for studies published in English between 1985 and 2006.

STUDY SELECTION AND DATA EXTRACTION

Among 923 articles found in the search, we identified 132 articles examining the associations between prescription drug plan cost-containment measures, including co-payments, tiering, or coinsurance (n = 65), pharmacy benefit caps or monthly prescription limits (n = 11), formulary restrictions (n = 41), and reference pricing (n = 16), and salient outcomes, including pharmacy utilization and spending, medical care utilization and spending, and health outcomes.

RESULTS

Increased cost sharing is associated with lower rates of drug treatment, worse adherence among existing users, and more frequent discontinuation of therapy. For each 10% increase in cost sharing, prescription drug spending decreases by 2% to 6%, depending on class of drug and condition of the patient. The reduction in use associated with a benefit cap, which limits either the coverage amount or the number of covered prescriptions, is consistent with other cost-sharing features. For some chronic conditions, higher cost sharing is associated with increased use of medical services, at least for patients with congestive heart failure, lipid disorders, diabetes, and schizophrenia. While low-income groups may be more sensitive to increased cost sharing, there is little evidence to support this contention.

CONCLUSIONS

Pharmacy benefit design represents an important public health tool for improving patient treatment and adherence. While increased cost sharing is highly correlated with reductions in pharmacy use, the long-term consequences of benefit changes on health are still uncertain.

Impact of pharmaceutical prior authorisation policies : a systematic review of the literature

Policies consisting of or including prior authorisation (PA) of pharmaceutical prescriptions have been increasingly implemented by public and private insurers in the last decade, especially in the US, in order to control drug spending. We conducted a systematic review of published articles determining the effects of these policies on drug use, healthcare utilisation, healthcare expenditures and health outcomes.A literature search was carried out in the electronic databases PubMed (which includes MEDLINE), EconLit, Web of Science and online sources including Google Scholar, from 1 January 1985 to 12 September 2006. Reference lists of retrieved articles were also searched. Peer-reviewed studies that provided empirical results about the impact of pharmaceutical PA policies, including randomised and non-randomised controlled trials, repeated measures studies, interrupted time series analyses and before-and-after studies were included. Use of, and expenditure on, directly affected drugs per patient, and overall drug expenditure, significantly decreased after PA implementation, or increased after PA removal. Health outcome changes attributed to PA policies were not directly evaluated. In most cases, except for cimetidine, PA implementation was not associated with significant changes in the utilisation of other medical services. Although the literature indicates a reduction in drug expenditure and a non-negative impact on use of other health services, policy recommendations still require improved study designs, and evidence cannot be easily transferred from one setting to another. The evidence still remains mainly limited to US Medicaid settings and to a small number of drug classes. There is a lack of consideration of implications of PA policies as heterogeneous interventions, outcome measurements require improvement, and there is a notable lack of evidence of medium- and long-term policy effects.