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Agarwal A, Stoff B. Ethics of using generative pretrained transformer and artificial intelligence systems for patient prior authorizations. J Am Acad Dermatol 2024; 90:1121-1122. [PMID: 37088200 DOI: 10.1016/j.jaad.2023.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/13/2023] [Accepted: 04/16/2023] [Indexed: 04/25/2023]
Affiliation(s)
- Aneesh Agarwal
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Benjamin Stoff
- Department of Dermatology, Emory School of Medicine, Atlanta, Georgia; Emory Center for Ethics, Atlanta, Georgia
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Sedghi T, Gronbeck C, Aiudi DA, Grant-Kels JM. Assessing the ethics of prior authorization denials and step therapy policies in dermatology. J Am Acad Dermatol 2024; 90:877-878. [PMID: 36822353 DOI: 10.1016/j.jaad.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 01/17/2023] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Affiliation(s)
- Tannaz Sedghi
- University of Connecticut School of Medicine, Farmington, Connecticut
| | - Christian Gronbeck
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut
| | - Donna A Aiudi
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut; Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida.
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Lizcano JD, Goh GS, Tarabichi S, Krueger CA, Austin MS, Courtney PM. Prior Authorization Leads to Administrative Burden and Delays in Treatment in Primary Total Joint Arthroplasty Patients. J Arthroplasty 2024:S0883-5403(24)00229-8. [PMID: 38493967 DOI: 10.1016/j.arth.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND The prior authorization (PA) process is often criticized by physicians due to increased administrative burden and unnecessary delays in treatment. The effects of PA policies on total hip arthroplasty (THA) and total knee arthroplasty (TKA) have not been well described. The purpose of this study was to analyze the use of PA in a high-volume orthopaedic practice across 4 states. METHODS We prospectively collected data on 28,725 primary THAs and TKAs performed at our institution between 2020 and 2023. Data collected included patient demographics, payer approval or denial, time to approval or denial, the number of initial denials, the number of peer-to-peer (P2P) or addenda, and the reasons for denial. RESULTS Seven thousand five hundred twenty eight (56.4%) patients undergoing THA and 8,283 (54%) patients undergoing TKA required PA, with a mean time to approval of 26.3 ± 34.6 and 33.7 ± 41.5 days, respectively. Addenda were requested in 608 of 7,528 (4.6%) THA patients and 737 of 8,283 (8.9%) TKA patients. From a total of 312 (4.1%) THA patients who had an initial denial, a P2P was requested for 50 (0.7%) patients, and only 27 (0.4%) were upheld after the PA process. From a total of 509 (6.1%) TKA patients who had an initial denial, a P2P was requested for 55 (0.7%) patients, and only 26 (0.3%) were upheld after the PA process. The mean time to denial in the THA group was 64.7 ± 83.5, and the most common reasons for denial were poor clinical documentation (25.9%) and lack of coverage (25.9%). The mean time to denial in the TKA group was 63.4 ± 103.9 days, and the most common reason for denial was not specified by the payer (46.1%). CONCLUSIONS The use of PA to approve elective THA and TKA led to increased surgical waiting times and a high administrative burden for surgeons and healthcare staff.
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Affiliation(s)
- Juan D Lizcano
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Graham S Goh
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Saad Tarabichi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Chad A Krueger
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Matthew S Austin
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Paul M Courtney
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Mizell R. The Impact of Insurance Restrictions in Newly Diagnosed Individuals With Multiple Sclerosis. Int J MS Care 2024; 26:17-21. [PMID: 38213675 PMCID: PMC10779716 DOI: 10.7224/1537-2073.2022-069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND The medical system in the United States has been riddled with insurance restrictions used by insurance companies to limit health care costs. The effects of insurance restrictions on patients receiving disease-modifying therapies for multiple sclerosis (MS) have not been specifically studied. METHODS A retrospective cross-sectional study of 52 individuals recently diagnosed with MS at a tertiary neurology clinic was conducted to measure the association between prior authorization (PA) duration and other variables of interest. The Cox proportional hazards model was used to determine likelihood of approval. Further analysis included multivariable logistic regression to assess the influence of variables of interest on the initial decision from the insurance company and the effect of the PA on disease activity. RESULTS Of 52 PAs, 50% were initially denied. An initial denial decreased the likelihood of approval by 98% (HR, 0.02; 95% CI, <0.01-0.09; P < .001). The odds of denial for oral medications (odds ratio [OR], 4.91; 95% CI, 1.33-21.52; P = .02) and infusions (OR, 8.35; 95% CI, 1.10-88.77; P = .05) were significantly higher than for injections. Medicaid had higher odds of denial compared with commercial insurance (OR, 4.51; 95% CI, 1.13-22.01; P = .04). An initial denial by insurance significantly increased the likelihood of disease activity (OR, 6.18; 95% CI, 1.33-44.86; P = .03). CONCLUSIONS Insurance restrictions delay necessary treatments, increase the likelihood of disease activity, and rarely change the approved disease-modifying therapy. Reducing PAs may lead to improved outcomes for patients with MS.
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Affiliation(s)
- Ryan Mizell
- From AdventHealth Neurology, Orlando, FL, USA
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5
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Andraka-Christou B, Golan O, Totaram R, Ohama M, Saloner B, Gordon AJ, Stein BD. Prior authorization restrictions on medications for opioid use disorder: trends in state laws from 2005 to 2019. Ann Med 2023; 55:514-520. [PMID: 36724766 PMCID: PMC9897778 DOI: 10.1080/07853890.2023.2171107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
RESEARCH OBJECTIVE Medications for opioid use disorder (MOUDs) - including methadone, buprenorphine, and naltrexone - are the most effective treatments for opioid use disorder (OUD). Historically, insurers have required prior authorization for MOUD, but prior authorization is often reported as a key barrier to MOUD prescribing. Some states have passed laws prohibiting MOUD prior authorization requirements. We sought to identify the frequency of MOUD prior authorization prohibitions in state laws and to categorize types of prohibitions. METHODS We searched for regulations and statutes present in all U.S. states and Washington DC between 2005 and 2019 using MOUD-related terms in Westlaw legal software. In qualitative software, we coded laws discussing MOUD prior authorization using template analysis - a mixed deductive/inductive approach. Finally, we used coded laws to identify frequencies of states with prior authorization prohibitions, including changes over time. RESULTS No states had laws prohibiting MOUD prior authorization between 2005 and 2015, with the first prohibition appearing in 2016. By 2019, fifteen states had MOUD prior authorization prohibitions. States varied significantly in their approach to prohibiting MOUD prior authorization. In 2019, it was more common for states to have MOUD prior authorization prohibitions applying to all insurers (n = 10 states) than to only Medicaid (n = 7 states) or only non-Medicaid insurers (n = 1 state). In 2019, general prior authorization prohibitions (n = 10 states) were more common than prohibitions only applicable to medications on the formulary, prohibitions only applicable to medications on the preferred drug list, prohibitions only applicable during the first 5 days of treatment, and prohibitions only applicable during the first 30 days of treatment. CONCLUSIONS The number of states with an MOUD prior authorization law prohibition increased in recent years. Such laws could help expand access to life-saving OUD treatments by making it easier for clinicians to prescribe MOUD.KEY MESSAGESNo states had MOUD prior authorization prohibitions between 2005 and 2015 in state statutes or regulations, and only one state had such a prohibition in 2016.By 2019, fifteen states had an MOUD prior authorization prohibition law.States varied significantly in their approach to prohibiting MOUD prior authorization, including with respect to the insurer type, duration of the prohibition, and applicable medication.
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Affiliation(s)
- Barbara Andraka-Christou
- School of Global Health Management and Informatics, University of Central Florida, Orlando, FL, USA
- Department of Internal Medicine (Secondary Joint Appointment), University of Central Florida, Orlando, FL, USA
- CONTACT Barbara Andraka-Christou School of Global Health Management and Informatics, University of Central Florida, 525 W Livingston Street, Suite 401, Orlando, 32801FL, USA
| | - Olivia Golan
- School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Rachel Totaram
- School of Global Health Management and Informatics, University of Central Florida, Orlando, FL, USA
| | - Maggie Ohama
- The Cardiac and Vascular Institute, Gainesville, FL, USA
| | - Brendan Saloner
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Adam J. Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Choi DK, Cohen NA, Choden T, Cohen RD, Rubin DT. Delays in Therapy Associated With Current Prior Authorization Process for the Treatment of Inflammatory Bowel Disease. Inflamm Bowel Dis 2023; 29:1658-1661. [PMID: 36715294 DOI: 10.1093/ibd/izad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Indexed: 01/31/2023]
Abstract
Lay Summary
Despite a high approval rate, there were unnecessary delays in therapy due to prior authorizations. This study identified the impact of type of IBD, FDA-labeled indication, and dose escalations on approvals.
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Affiliation(s)
- David K Choi
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Nathaniel A Cohen
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Tenzin Choden
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Russell D Cohen
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - David T Rubin
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
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Liu BY, Kazi DS. Economic and Ethical Case for Eliminating Patient Out-of-Pocket Costs. Circ Cardiovasc Qual Outcomes 2023; 16:e010142. [PMID: 37847752 DOI: 10.1161/circoutcomes.123.010142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Affiliation(s)
- Benjamin Y Liu
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (B.Y.L.)
| | - Dhruv S Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (D.S.K.)
- Harvard Medical School, Boston, MA (D.S.K.)
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Chen M, Zhou AE, Grant-Kels JM. Ethics of free sample of biologics and prior authorization. J Am Acad Dermatol 2023:S0190-9622(23)02869-4. [PMID: 37769900 DOI: 10.1016/j.jaad.2023.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/05/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Maggie Chen
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Albert E Zhou
- Department of Dermatology, University of Connecticut, Farmington, Connecticut
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut, Farmington, Connecticut; Department of Dermatology, University of Florida, Gainesville, Florida.
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Goh GS, Schwartz AM, Friend JK, Grace TR, Wickes CB, Bolognesi MP, Austin MS. Patients Who Have Kellgren-Lawrence Grade 3 and 4 Osteoarthritis Benefit Equally From Total Knee Arthroplasty. J Arthroplasty 2023; 38:1714-1717. [PMID: 37019313 DOI: 10.1016/j.arth.2023.03.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/18/2023] [Accepted: 03/23/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Recently, some payers have limited access to total knee arthroplasty (TKA) to patients who have Kellgren-Lawrence (KL) grade 4 osteoarthritis only. This study compared the outcomes of patients who have KL grade 3 and 4 osteoarthritis after TKA to determine if this new policy is justified. METHODS This was a secondary analysis of a series originally established to collect outcomes for a single, cemented implant design. A total of 152 patients underwent primary, unilateral TKA at two centers from 2014 to 2016. Only patients who had KL grade 3 (n = 69) or 4 (n = 83) osteoarthritis were included. There was no difference in age, sex, American Society of Anesthesiologists score, or preoperative Knee Society Score (KSS) between the groups. Patients who had KL grade 4 disease had a higher body mass index. KSS and Forgotten Joint Score (FJS) were collected preoperatively and at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Generalized linear models were used to compare outcomes. RESULTS Controlling for demographics, improvements in KSS were comparable between the groups at all time points. There was no difference in KSS, FJS, and the proportion that achieved the patient acceptable symptom state for FJS at 2 years. CONCLUSION Patients who had KL grade 3 and 4 osteoarthritis experienced similar improvement at all time points up to 2 years after primary TKA. There is no justification for payers to deny access to surgical treatment for patients who have KL grade 3 osteoarthritis and have otherwise failed nonoperative treatment.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts
| | - Andrew M Schwartz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jennifer K Friend
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Trevor R Grace
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - C Baylor Wickes
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew S Austin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Lambrechts MJ. Obtaining lumbar spine magnetic resonance imaging is burdensome: can we fix it? J Spine Surg 2023; 9:114-116. [PMID: 37435325 PMCID: PMC10331492 DOI: 10.21037/jss-23-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 04/16/2023] [Indexed: 07/13/2023]
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Sehanobish E, Ye K, Imam K, Sariahmed K, Kurian J, Patel J, Belletti D, Chung Y, Jariwala S, White A, Jerschow E. Elaborate biologic approval process delays care of patients with moderate-to-severe asthma. J Allergy Clin Immunol Glob 2023; 2:100076. [PMID: 37780792 PMCID: PMC10509902 DOI: 10.1016/j.jacig.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/08/2022] [Accepted: 10/19/2022] [Indexed: 10/03/2023]
Abstract
Background mAbs (biologics) are indicated in patients with poorly controlled moderate-to-severe asthma. The process of prior authorization and administration of a biologic requires exceptional commitment from clinical teams. Objective Our aim was to evaluate the process of approval and administration of biologics for asthma and determine the most common reasons associated with denials of biologics and delays in administration. Methods We examined the records of patients with asthma who were prescribed biologics from January 2018 to January 2020 at 2 centers, Montefiore Medical Center (Bronx, NY) and Scripps Clinics (San Diego, Calif). Demographics, insurance information, and details on the approval process were collected. Results After querying of electronic health records, the records of 352 and 70 patients with moderate-to-severe asthma were included from Montefiore and Scripps, respectively. Most patients at Montefiore (58.2%) were insured under Managed Care Medicaid (MC Medicaid), whereas most patients at Scripps (61.4%) had commercial insurance. The median times from prescription to administration of a biologic were similar: 34 days (interquartile range [IQR] = 18-63 days) and 34 days (IQR = 22.5-56.0 days) (P = .97) for Montefiore and Scripps, respectively. However, the median approval time for Montefiore was 6 days (IQR = 1-20 days) and that for Scripps was 22 days (IQR = 10-36 days) (P < .001). Approval times for prescriptions requiring appeals were significantly longer than for prescriptions approved after the initial submission: 23 days versus 2.5 days and 40.5 days versus 15.5 days (for Montefiore and Scripps, respectively [P < .001 for both]). Conclusions Lengthy appeals contribute to delays between prescribing and administering a biologic. Site-specific practices and insurance coverage influence approval timing of the biologics for asthma.
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Affiliation(s)
- Esha Sehanobish
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Kenny Ye
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | | | - Karim Sariahmed
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Joshua Kurian
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | | | | | - Yen Chung
- AstraZeneca Pharmaceuticals, Wilmington, De
| | - Sunit Jariwala
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | | | - Elina Jerschow
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
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Lenert LA, Lane S, Wehbe R. Could an artificial intelligence approach to prior authorization be more human? J Am Med Inform Assoc 2023; 30:989-994. [PMID: 36809561 PMCID: PMC10114030 DOI: 10.1093/jamia/ocad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/23/2023] [Accepted: 02/02/2023] [Indexed: 02/23/2023] Open
Abstract
Prior authorization (PA) may be a necessary evil within the healthcare system, contributing to physician burnout and delaying necessary care, but also allowing payers to prevent wasting resources on redundant, expensive, and/or ineffective care. PA has become an "informatics issue" with the rise of automated methods for PA review, championed in the Health Level 7 International's (HL7's) DaVinci Project. DaVinci proposes using rule-based methods to automate PA, a time-tested strategy with known limitations. This article proposes an alternative that may be more human-centric, using artificial intelligence (AI) methods for the computation of authorization decisions. We believe that by combining modern approaches for accessing and exchanging existing electronic health data with AI methods tailored to reflect the judgments of expert panels that include patient representatives, and refined with "few shot" learning approaches to prevent bias, we could create a just and efficient process that serves the interests of society as a whole. Efficient simulation of human appropriateness assessments from existing data using AI methods could eliminate burdens and bottlenecks while preserving PA's benefits as a tool to limit inappropriate care.
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Affiliation(s)
- Leslie A Lenert
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Steven Lane
- Health Gorilla, Mountain View, California, USA
| | - Ramsey Wehbe
- Department of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
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Woelber E, Rana AJ, Springer BD, Kerr JM, Courtney PM, Krueger CA. Health Policy Views and Political Advocacy of Arthroplasty Surgeons: A Survey of the American Association of Hip and Knee Surgeons Members. J Arthroplasty 2023:S0883-5403(23)00091-8. [PMID: 36773663 DOI: 10.1016/j.arth.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/24/2023] [Accepted: 02/01/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND The American Association of Hip and Knee Surgeons (AAHKS) is the largest specialty society for arthroplasty surgeons in the United States and is dedicated to education, research, and advocacy. The purpose of this study was to identify the health policy views of AAHKS members and better characterize their advocacy participation. METHODS A 22 question survey was electronically distributed multiple times via email link to all 3,638 United States members of AAHKS who were in practice or training in 2022. Study results were analyzed using descriptive statistics. RESULTS There were 311 responses (9%), with 18% of respondents being within 5 years of practice and 38% having more than 20 years of practice. Respondents identified as Republicans (40%), Independents (37%), and Democrats (21%). Top policy issues included preserving physician reimbursement and equitable fee schedule representation (95%), the burden of prior authorization (53%), the impact of Center of Medicare and Medicaid Services regulations (39%), and medical liability and tort reform (39%). Members ranked maintaining appropriate physician reimbursement (44%) and advocating for patients (37%) as the top benefits to participation in advocacy. A majority of respondents (81%) stated that they spend more time on presurgery optimization now than 10 years ago. The most common barrier to advocacy participation was a lack of time (77%). CONCLUSION Responding AAHKS members are well-informed, politically engaged, patient-oriented, and eager for a voice in policy decisions that affect the professional future of arthroplasty surgeons. These results can be used to help direct strategic efforts of the AAHKS Advocacy Committee to further increase advocacy efforts.
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Affiliation(s)
- Erik Woelber
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Adam J Rana
- Department of Orthopaedics & Sports Medicine, Maine Medical Partners, South Portland, Maine
| | | | - Joshua M Kerr
- American Association of Hip and Knee Surgeons, Chicago, Illinois
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Goh GS, Tarabichi S, Baker CM, Qadiri QS, Austin MS. Should We Aim to Help Patients "Feel Better" or "Feel Good" After Total Hip Arthroplasty? Determining Factors Affecting the Achievement of the Minimal Clinically Important Difference and Patient Acceptable Symptom State. J Arthroplasty 2023; 38:293-299. [PMID: 35964857 DOI: 10.1016/j.arth.2022.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/04/2022] [Accepted: 08/07/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Recent attempts have been made to use preoperative patient-reported outcome measure (PROM) thresholds as prior authorization criteria based on the assumption that patients who have higher baseline scores are less likely to achieve the minimal clinically important difference (MCID). This study aimed to identify factors affecting the achievement of MCID and patient acceptable symptom state (PASS) after total hip arthroplasty (THA), and to determine the overlap between the two outcomes. METHODS We identified 3,581 primary, unilateral THAs performed at a single practice in 2015-2019. PROMs including Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) and 12-item Short Form Health Survey were collected preoperatively and 1-year postoperatively. The likelihood of attaining PASS according to attainment of MCID was assessed. Multivariable regression was used to identify independent predictors of MCID and PASS. RESULTS In total, 79.8% achieved MCID and 73.6% achieved PASS for HOOS-JR. Approximately 1 in 7 patients who achieved MCID did not eventually achieve PASS. Worse preoperative HOOS-JR (odd ratio 0.933) was associated with MCID attainment. Better preoperative HOOS-JR (odd ratio 1.015) was associated with PASS attainment. Men, lower body mass index, better American Society of Anesthesiologists score, and better preoperative 12-item Short Form Health Survey mental score were predictors of MCID and PASS. Age, race, ethnicity, Charlson Comorbidity Index, and smoking status were not significant predictors. CONCLUSION Preoperative PROMs were associated with achieving MCID and PASS after THA, albeit in opposite directions. Clinicians should strive to help patients "feel better" and "feel good" after surgery. Preoperative PROMs should not solely be used to prioritize access to care.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Colin M Baker
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Qudratullah S Qadiri
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew S Austin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Pereira DE, Kamara E, Krueger CA, Courtney PM, Austin MS, Rana A, Hannon CP. Prior Authorization in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership. J Arthroplasty 2023:S0883-5403(23)00042-6. [PMID: 36708936 DOI: 10.1016/j.arth.2023.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND This study surveyed the impact that prior authorization has on the practices of total joint arthroplasty (TJA) members of the American Association of Hip and Knee Surgeons (AAHKS). METHODS A 24-question survey was approved by the AAHKS Advocacy Committee and distributed to all 2,802 board-certified members of AAHKS. RESULTS There were 353 survey responses (13%). Ninety-five percent of surgeons noted a 5-year increase in prior authorization. A majority (71%) of practices employ at least 1 staff member to exclusively work on prior authorization. Average time spent on prior authorization was 15 h/wk (range, 1 to 125) and average number of claims peer week was 18 (range, 1 to 250). Surgeries (99%) were the most common denial. These were denied because nonoperative treatment had not been tried (71%) or had not been attempted for enough time (67%). Most (57%) prior authorization processes rarely/never changed the treatment provided. Most (56%) indicated that prior authorization rarely/never followed evidence-based guidelines. A majority (93%) expressed high administrative burden as well as negative clinical outcomes (87%) due to prior authorization including delays to access care (96%) at least sometimes. DISCUSSION Prior authorization has increased in the past 5 years resulting in high administrative burden. Prior authorizations were most common for TJA surgeries because certain nonoperative treatments were not attempted or not attempted for enough time. Surgeons indicated that prior authorization may be detrimental to high-value care and lead to potentially harmful delays in care without ultimately changing the management of the patient.
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Affiliation(s)
- Daniel E Pereira
- Department of Orthopaedic Surgery, Washington University, Saint Louis, Missouri
| | - Eli Kamara
- Orthopaedic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York
| | - Chad A Krueger
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew S Austin
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Adam Rana
- Maine Medical Partners Orthopedics and Sports Medicine, South Portland, Maine
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Washington University, Saint Louis, Missouri
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Erlandson E, Ramirez C, Dean W. Medicine shouldn't be this hard: The intersection of physician moral injury and patient healthcare experience in pediatric complex care. J Pediatr Rehabil Med 2023; 16:443-447. [PMID: 37694318 PMCID: PMC10578270 DOI: 10.3233/prm-230027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Dr. Jay Neufeld's story in If I Betray These Words is a detailed account of one physician's catastrophic journey through moral injury when caring for pediatric patients with complex medical conditions [1]. Many clinicians may recognize Jay's journey in their own experiences, but what deserves parallel consideration are the journeys of patients and families when they are accompanied by physicians at risk of moral injury. This case study illustrates the tight link between drivers of physician moral injury and patients' negative healthcare experiences. These include (1) decisions directed by health insurance regulations and prior authorizations; (2) the electronic medical record (EMR); and (3) healthcare systems focused on revenue generation.
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Affiliation(s)
- Erika Erlandson
- Departments of Pediatrics and Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine, Lansing, MI, USA
| | | | - Wendy Dean
- Moral Injury of Healthcare, Carlisle, PA, USA
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Omar D, Brown-Korsah JB, Taylor SC, Mollanazar N. Automated pharmacy substitution for medications not covered by Medicaid: A model for reducing the burden of prior authorizations in dermatology. J Am Acad Dermatol 2023; 88:258-260. [PMID: 36184007 DOI: 10.1016/j.jaad.2022.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Deega Omar
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Jessica B Brown-Korsah
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Susan C Taylor
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas Mollanazar
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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18
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Goh GS, Baker CM, Tarabichi S, Clark SC, Austin MS, Lonner JH. The Paradox of Patient-Reported Outcome Measures: Should We Prioritize "Feeling Better" or "Feeling Good" After Total Knee Arthroplasty? J Arthroplasty 2022; 37:1751-1758. [PMID: 35436528 DOI: 10.1016/j.arth.2022.04.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The use of preoperative patient-reported outcome measure (PROM) thresholds for patient selection in arthroplasty care has been questioned recently. This study aimed to identify factors affecting achievement of the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) after total knee arthroplasty (TKA) and determine the overlap between the two outcomes. METHODS We identified 1,239 primary, unilateral TKAs performed at a single institution in 2015-2019. PROMs including the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and 12-item Short Form Health Survey (SF-12) were collected preoperatively and 1-year postoperatively. The likelihood of attaining PASS as per attainment of MCID was assessed. A multivariable regression was used to identify predictors of MCID and PASS. RESULTS In total, 71.3% achieved MCID and 75.5% achieved PASS for KOOS-JR. Only 7.7% achieved MCID but not PASS, whereas almost twice this number did not achieve MCID but did achieve PASS (11.9%). Poorer preoperative KOOS-JR (OR 0.925), better SF-12 physical (OR 1.025), and mental (OR 1.027) were associated with MCID attainment. In contrast, better preoperative KOOS-JR (OR 1.030) and SF-12 mental (OR 1.025) were associated with PASS attainment. Age, gender, race, ethnicity, body mass index, Charlson index, American Society of Anesthesiologists classification, and smoking status were not significant predictors. CONCLUSION Preoperative PROMs were associated with achieving MCID and PASS after TKA, albeit some positively and some negatively. In the era of value-based care, clinicians should not only strive to help patients "feel better" but also ensure that patients "feel good" after surgery. This study does not support the use of PROMs in prioritizing access to care.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Colin M Baker
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Sean C Clark
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Matthew S Austin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Jess H Lonner
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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19
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Sadigh G, Goeckner HG, Kazerooni EA, Johnson BE, Smith RA, Adams DV, Carlos RC. State legislative trends related to biomarker testing. Cancer 2022; 128:2865-2870. [PMID: 35607821 DOI: 10.1002/cncr.34271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/13/2022] [Accepted: 04/25/2022] [Indexed: 11/06/2022]
Abstract
Comprehensive biomarker testing has become the standard of care for informing the choice of the most appropriate targeted therapy for many patients with advanced cancer. Despite evidence demonstrating the need for comprehensive biomarker testing to enable the selection of appropriate targeted therapies and immunotherapy, the incorporation of biomarker testing into clinical practice lags behind recommendations in National Comprehensive Cancer Network guidelines. Coverage policy differences across insurance health plans have limited the accessibility of comprehensive biomarker testing largely to patients whose insurance covers the recommended testing or those who can pay for the testing, and this has contributed to health disparities. Furthermore, even when insurance coverage exists for recommended biomarker testing, patients may incur burdensome out-of-pocket costs depending on their insurance plan benefits, which may also create barriers to testing. Prior authorization for biomarker testing for some patients can add an administrative burden and may delay testing and thus treatment if it is not done in a timely manner. Recently, three states (Illinois, Louisiana, and California) passed laws designed to improve access to biomarker testing at the state level. However, there is variability among these laws in terms of the population affected, the stage of cancer, and whether the coverage of testing is mandated, or the legislation addresses only prior authorization. Advocacy efforts by patient advocates, health care professionals, and professional societies are imperative at the state level to further improve coverage for and access to appropriate biomarker testing.
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Affiliation(s)
- Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hilary Gee Goeckner
- American Cancer Society Cancer Action Network, Inc, Washington, District of Columbia, USA
| | - Ella A Kazerooni
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Bruce E Johnson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Robert A Smith
- Early Cancer Detection Science, American Cancer Society, Atlanta, Georgia, USA
| | - Devon V Adams
- American Cancer Society Cancer Action Network, Inc, Washington, District of Columbia, USA
| | - Ruth C Carlos
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
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Parish WJ, Mark TL, Zarkin GA, Weber E. The association of Medicare Part D prior authorization for buprenorphine-naloxone with adherence to opioid use disorder treatment guidelines in the United States. Addiction 2022; 117:141-150. [PMID: 34033177 DOI: 10.1111/add.15585] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 12/07/2020] [Accepted: 05/12/2021] [Indexed: 11/28/2022]
Abstract
AIMS To assess differences in the quality of opioid use disorder (OUD) treatment received by Medicare beneficiaries enrolled in health plans that used prior authorization (PA) for buprenorphine-naloxone compared with those enrolled in plans that did not use PA. DESIGN, SETTING AND PARTICIPANTS Cross-sectional observational study, United States. Continuously enrolled beneficiaries (71 294) with an OUD who filled at least one prescription for buprenorphine-naloxone between March 2012 and July 2017. MEASUREMENTS Percentage of patients tested for hepatis B, hepatis C, HIV and liver functioning; percentage of patients with urine drug screens and number of urine drug screens; continuous use of buprenorphine-naloxone for at least 180 days; co-use of benzodiazepines; number of outpatient visits with and without an OUD diagnosis. FINDINGS PA was significantly associated with a lower likelihood of testing for hepatitis B [-3.5, 95% confidence interval (CI) = -4.4, -2.7] and C (-5.9, 95% CI = -6.9, -4.9), but the findings were inconclusive as to whether or not there was a difference in HIV (-1.1, 95% CI = -2.5, 0.4) or liver function testing (1.3, 95% CI = -0.1, 2.7). PA was associated with a lower likelihood of urine drug screening (-25.5, 95% CI = -26.8, -24.1) and with fewer drug screens (-2.5, 95% CI = -3.0, -2.1). Findings were inconclusive as to whether or not there was a difference in continuous use of buprenorphine-naloxone (0.3, 95% CI = -1.2, 1.8). PA was associated with fewer outpatient visits (-2.1, 95% CI = -3.0, -1.2) and fewer outpatient visits with an OUD diagnosis (-1.7, 95% CI = -2.1, -1.3). PA was associated with a lower likelihood of filling benzodiazepine prescriptions before and after buprenorphine-naloxone induction (-28.9, 95% CI = -29.6, -28.3) but a greater likelihood of only using benzodiazepines after buprenorphine-naloxone induction (10.6, 95% CI = 9.3, 11.8). CONCLUSIONS US Medicare patients subject to prior authorization for buprenorphine-naloxone are not more likely to receive high-quality treatment for opioid use disorder than patients not subject to prior authorization.
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21
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Marble KY, Briggs GR, Gordy XZ. Improvements for the Prior Authorization Process for Elective Surgical Procedures at an Academic Medical Center. Perspect Health Inf Manag 2022; 19:1l. [PMID: 35440929 PMCID: PMC9013228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Prior authorization is an approval process to ensure that services provided by healthcare organizations will be reimbursed by insurance carriers. Prior authorization denials can result in revenue loss. Due to multiple prior authorization issues, over $21 million in charges was denied, and $291,217.63 was ultimately written off as uncollectible in a one-year period at the Department of Surgery at Hospital X. This paper aimed to design an improved process to reduce, or eliminate, the issues causing charges to be written off. Three divisions with the most prior authorization denials within the department were identified. A comprehensive review of the current prior authorization process was conducted. Each division was found to have a unique prior authorization issue that was causing charges to be written off. Barriers were identified, educational training was provided accordingly, and process changes were implemented thereafter. When comparing the results pre- and post-interventions, these interventions resulted in these charges no longer being denied or written off. The processes utilized here can be easily replicated for organizations with similar barriers.
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22
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Anderson A, McCoy L, Pettit RS, Wright BA, Lubsch L. Early insurance coverage of elexacaftor/tezacaftor/ivacaftor for cystic fibrosis. Pediatr Pulmonol 2021; 56:4053-4054. [PMID: 34499822 DOI: 10.1002/ppul.25659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 11/06/2022]
Affiliation(s)
| | - Lindsey McCoy
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rebecca S Pettit
- Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA
| | | | - Lisa Lubsch
- Southern Illinois University Edwardsville School of Pharmacy and SSM Health Cardinal Glennon Children's Hospital, Edwardsville, Illinois, USA
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23
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Ozaki AF, Krumholz HM, Mody FV, Tran TT, Le QT, Yokota M, Jackevicius CA. Prior Authorization, Copayments, and Utilization of Sacubitril/Valsartan in Medicare and Commercial Plans in Patients With Heart Failure With Reduced Ejection Fraction. Circ Cardiovasc Qual Outcomes 2021; 14:e007665. [PMID: 34465124 DOI: 10.1161/circoutcomes.120.007665] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Slow uptake of sacubitril/valsartan in patients with heart failure with reduced ejection fraction has been reported, which may negatively impact clinical outcomes. We characterized prior authorization (PA) burden, prescription copayment, and utilization of sacubitril/valsartan by insurance plan type to identify potential barriers to its use. METHODS We conducted a national population-level, cross-sectional study using PA data from an insurance coverage website accessed in March 2019 and IQVIA National Prescription Audit data from August 2018 to July 2019. Primary outcomes were proportion of plans requiring PA, frequency of specific PA criteria, number of sacubitril/valsartan prescriptions, and copayments per insurance plan type. RESULTS Overall, 48.1% (1394/2896) of insurance plans required PA for sacubitril/valsartan. Fewer Medicare (27.7%) than commercial (57.2%) plans required PA (P<0.001). For both plan types, the most frequently required PA criteria were ejection fraction (71.6%, 90.9%) and New York Heart Association class (60.4%, 90.8%) for Medicare and commercial plans, respectively. Copayment amounts varied by plan type, with more sacubitril/valsartan prescriptions for commercial plans not requiring a patient copayment (32.4%) compared with Medicare plans (19.3%; P<0.001). There were 814 437 sacubitril/valsartan prescriptions for Medicare and 822 292 for commercial plans dispensed from August 2018 to July 2019. Based on estimated heart failure with reduced ejection fraction populations for each plan type, 4-fold more sacubitril/valsartan prescriptions were dispensed in commercial than in Medicare plans (820 versus 215 prescriptions/1000 individuals in the heart failure with reduced ejection fraction population). The estimated proportion of heart failure with reduced ejection fraction patients prescribed sacubitril/valsartan was 3.6% (1.5%-6.8%) for Medicare and 13.7% (4.9%-31.8%) for commercial plan populations. CONCLUSIONS Despite commercial plans having greater PA requirements than Medicare, population-adjusted use of sacubitril/valsartan was higher in commercial plans. Given that commercial plans had more prescriptions with low copayments than Medicare, copayment policies may be more influential on sacubitril/valsartan use than its PA policies. Low sacubitril/valsartan use in both plan types highlights the multifactorial nature of medication underutilization that includes factors beyond the drug policies that we evaluated.
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Affiliation(s)
- Aya F Ozaki
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA (A.F.O., T.T.T., Q.T.L., M.Y., C.A.J.).,Department of Pharmacy, Veterans Affairs Greater Los Angeles Healthcare System, CA (A.F.O., C.A.J.)
| | - Harlan M Krumholz
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (H.M.K.).,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.)
| | - Freny Vaghaiwalla Mody
- Division of Cardiology, Veterans Affairs Greater Los Angeles Healthcare System, CA (F.V.M.).,David Geffen School of Medicine, University of California, Los Angeles, CA (F.V.M.)
| | - Tien T Tran
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA (A.F.O., T.T.T., Q.T.L., M.Y., C.A.J.)
| | - Quan T Le
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA (A.F.O., T.T.T., Q.T.L., M.Y., C.A.J.)
| | - Mai Yokota
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA (A.F.O., T.T.T., Q.T.L., M.Y., C.A.J.)
| | - Cynthia A Jackevicius
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA (A.F.O., T.T.T., Q.T.L., M.Y., C.A.J.).,Department of Pharmacy, Veterans Affairs Greater Los Angeles Healthcare System, CA (A.F.O., C.A.J.).,ICES, Toronto, ON, Canada (C.A.J.).,Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada (C.A.J.)
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24
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Freitag FG. Everything old is new again. Headache 2021; 61:1286. [PMID: 34350590 DOI: 10.1111/head.14181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/09/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Frederick G Freitag
- Headache Medicine and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
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25
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Jenkins TC, Tamma PD. Thinking Beyond the "Core" Antibiotic Stewardship Interventions: Shifting the Onus for Appropriate Antibiotic Use from Stewardship Teams to Prescribing Clinicians. Clin Infect Dis 2021; 72:1457-1462. [PMID: 32667974 DOI: 10.1093/cid/ciaa1003] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/10/2020] [Indexed: 01/31/2023] Open
Abstract
United States guidance for hospital antibiotic stewardship has emphasized prospective audit and feedback and prior authorization of select antibiotics as core interventions. These remain the most common interventions implemented by stewardship programs. Although these approaches have been shown to reduce unnecessary antibiotic use, they incorrectly put the onus for appropriate antibiotic use on the stewardship team rather than the prescribing clinician. We propose that a primary focus of stewardship programs should be implementation of broader interventions that engage frontline clinicians and equip them with tools to integrate antibiotic stewardship into their own daily practice, thus reducing the need for day-to-day stewardship team oversite. We discuss a framework of broader interventions and policies that will facilitate this paradigm shift.
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Affiliation(s)
- Timothy C Jenkins
- Department of Medicine and Division of Infectious Diseases, Denver Health, Denver, Colorado, USA.,Department of Patient Safety and Quality, Denver Health, Denver, Colorado, USA.,Department of Medicine and Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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26
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Inoue K, Figueroa JF, DeJong C, Tsugawa Y, Orav EJ, Shen C, Kazi DS. Association Between Industry Marketing Payments and Prescriptions for PCSK9 (Proprotein Convertase Subtilisin/Kexin Type 9) Inhibitors in the United States. Circ Cardiovasc Qual Outcomes 2021; 14:e007521. [PMID: 33966446 DOI: 10.1161/circoutcomes.120.007521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Marketing payments from the pharmaceutical industry to physicians have come under scrutiny due to their potential to influence clinical decision-making. Two proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) were approved by the US Food and Drug Administration in 2015 for reducing low-density lipoprotein cholesterol in high-risk patients, but their initial uptake was limited due to their high-cost and stringent prior authorization requirements. We sought to investigate the association between industry marketing and early adoption of PCSK9i among US physicians. METHODS We used nationwide databases of primary care physicians, cardiologists, and endocrinologists treating Medicare beneficiaries to examine the association between PCSK9i-related marketing payments in 2016 and the number of filled PCSK9i prescriptions in 2017, after adjusting for physician characteristics. In subgroup analyses, we stratified our analyses by physician specialty and prior experience with prescribing PCSK9i. RESULTS Among 209 840 physicians included in this analysis, 49 341 (24%) physicians received 292 941 PCSK9i-related marketing payments in 2016. The total value of these payments was $19 million, with a median payment of $61 per physician (interquartile range, $25-$132). Most payments (95%) were for meals, with a median of $14 per meal. The receipt of PCSK9i-related payments in 2016 was associated with increased PCSK9i prescription in 2017 (adjusted risk ratio, 3.18 [95% CI, 2.95-3.42]). This association was larger among primary care physicians (adjusted risk ratio, 6.67 [95% CI, 5.87-7.57]) than cardiologists (adjusted risk ratio, 2.00 [95% CI, 1.84-2.16]) and endocrinologists (adjusted risk ratio, 4.06 [95% CI, 2.95-5.59]). The association was observed across all types of payments. CONCLUSIONS At a time when few physicians had experience with prescribing PCSK9i under strict prior authorization requirements, industry marketing payments to physicians for PCSK9i, predominantly in the form of meals, were associated with increased PCSK9i prescription in the subsequent year.
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Affiliation(s)
- Kosuke Inoue
- Department of Epidemiology (K.I.) UCLA Fielding School of Public Health.,Department of Social Epidemiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan (K.I.)
| | - Jose F Figueroa
- Department of Health Policy and Management (J.F.F., E.J.O.) Harvard T.H. Chan School of Public Health, Boston, MA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA (J.F.F.)
| | - Colette DeJong
- Department of Medicine, University of California, San Francisco School of Medicine (C.D.)
| | - Yusuke Tsugawa
- Department of Health Policy and Management (Y.T.), UCLA Fielding School of Public Health.,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA (Y.T.)
| | - E John Orav
- Department of Health Policy and Management (J.F.F., E.J.O.) Harvard T.H. Chan School of Public Health, Boston, MA.,Department of Biostatistics (E.J.O.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.S., D.S.K.).,Harvard Medical School, Boston, MA (C.S., D.S.K.)
| | - Dhruv S Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.S., D.S.K.)
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27
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Martirosov AL, Smith ZR, Hencken L, MacDonald NC, Griebe K, Fantuz P, Grafton G, Hegab S, Ismail R, Jackson B, Kelly B, Miller M, Awdish R. Improving transitions of care for critically ill adult patients on pulmonary arterial hypertension medications. Am J Health Syst Pharm 2021; 77:958-965. [PMID: 32495842 DOI: 10.1093/ajhp/zxaa079] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The purpose of this report is to describe the activities of critical care and ambulatory care pharmacists in a multidisciplinary transitions-of-care (TOC) service for critically ill patients with pulmonary arterial hypertension (PAH) receiving PAH medications. SUMMARY Initiation of medications for treatment of PAH involves complex medication access steps. In the ambulatory care setting, multidisciplinary teams often have a process for completing these steps to ensure access to PAH medications. Patients with PAH are frequently admitted to an intensive care unit (ICU), and their home PAH medications are continued and/or new medications are initiated in the ICU setting. Inpatient multidisciplinary teams are often unfamiliar with the medication access steps unique to PAH medications. The coordination and completion of medication access steps in the inpatient setting is critical to ensure access to medications at discharge and prevent delays in care. A PAH-specific TOC bundle for patients prescribed a PAH medication who are admitted to the ICU was developed by a multidisciplinary team at an academic teaching hospital. The service involves a critical care pharmacist completing a PAH medication history, assessing for PAH medication access barriers, and referring patients to an ambulatory care pharmacist for postdischarge telephone follow-up. In collaboration with the PAH multidisciplinary team, a standardized workflow to be initiated by the critical care pharmacist was developed to streamline completion of PAH medication access steps. Within 3 days of hospital discharge, the ambulatory care pharmacist calls referred patients to ensure access to PAH medications, provide disease state and medication education, and request that the patient schedule a follow-up office visit to take place within 14 days of discharge. CONCLUSION Collaboration by a PAH multidisciplinary team, critical care pharmacist, and ambulatory care pharmacist can improve TOC related to PAH medication access for patients with PAH. The PAH TOC bundle serves as a model that may be transferable to other health centers.
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Affiliation(s)
| | | | | | | | | | | | | | - Sara Hegab
- Henry Ford Hospital, Detroit, MI, and Wayne State University School of Medicine, Detroit, MI
| | | | | | | | | | - Rana Awdish
- Henry Ford Hospital, Detroit, MI, and Wayne State University School of Medicine, Detroit, MI
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Jones EM, Francart SJ, Amerine LB. Embedding an Advanced Pharmacy Technician in an Adult Specialty Pulmonary Clinic to Complete Prior Authorizations Improves Efficiency and Provider Satisfaction. J Pharm Pract 2021; 35:551-558. [PMID: 33648372 DOI: 10.1177/0897190021997007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this study is to assess the impact of a clinic embedded Medication Assistance Program (MAP) specialist on the prescription benefit prior authorization (PA) process and provider satisfaction in an adult pulmonary clinic. METHODS In this mixed methods study, a retrospective cohort analysis was done to determine the turnaround time for the PA process from initial referral to approval or final denial in an adult pulmonary clinic. Additionally, a pre- and post-implementation survey to providers was conducted to assess provider satisfaction and perceptions around the prescription benefit PA process. The first study aim assessed PA efficiency by summarizing PA approval rate and PA turnaround time using descriptive statistics. Any prescriptions written by a clinic provider requiring a PA during the timeframe of June 2018 through August 2018 were included. The second study aim assessed change in provider satisfaction, analyzed via the Mann-Whitney U test. RESULTS The MAP specialist completed 110 PAs over 3 months for 110 unique patients. Median turnaround time was 3 hours, with 76% of PAs approved in less than 24 hours. Initial approval rate was 82.7%, and overall approval rate following the appeals process was 87.3%. A significant difference between the pre- and post-survey responses were identified in 2 of the 17 questions. CONCLUSION Implementation of a clinic embedded MAP specialist to complete PAs demonstrated an efficient process while also improving provider satisfaction.
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Affiliation(s)
- Emily M Jones
- Department of Pharmacy, Spectrum Health, Holland, MI, USA
| | - Suzanne J Francart
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Lindsey B Amerine
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA.,UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, NC, USA
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Pearson SD, Towse A, Lowe M, Segel CS, Henshall C. Cornerstones of 'fair' drug coverage: appropriate cost sharing and utilization management policies for pharmaceuticals. J Comp Eff Res 2021; 10:537-547. [PMID: 33646012 DOI: 10.2217/cer-2021-0027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
At the heart of all health insurance programs lies ethical tension between maximizing the freedom of patients and clinicians to tailor care for the individual and the need to make healthcare affordable. Nowhere is this tension more fiercely debated than in benefit design and coverage policy for pharmaceuticals. This paper focuses on three areas over which there is the most controversy about how to judge whether drug coverage is appropriate: cost-sharing provisions, clinical eligibility criteria, and economic-step therapy and required switching. In each of these domains we present 'ethical goals for access' followed by a series of 'fair design criteria' that can be used by stakeholders to drive more transparent and accountable drug coverage.
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Affiliation(s)
| | | | - Maria Lowe
- Institute for Clinical & Economic Review, Boston, MA 02109, USA
| | - Celia S Segel
- Institute for Clinical & Economic Review, Boston, MA 02109, USA
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30
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Latronica JR. Increasing access to medications for opioid use disorder: Policy analysis and proposals. J Addict Dis 2021; 39:421-424. [PMID: 33616013 DOI: 10.1080/10550887.2021.1882650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Opioid overdose continues to be the leading cause of accidental death in the United States, and the prevalence of OUD continues to increase. Increased access to health insurance-specifically in regard to state-funded Medicaid programs-as well as robust formularies and limited prior authorization have been demonstrated to be effective both in treating patients with OUD, as well as producing cost savings for government and commercial payors.
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Affiliation(s)
- James R Latronica
- Department of Pediatrics-Addiction Medicine, Penn State Health, Hershey, PA, USA
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31
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Gaskin CM, Ellenbogen AL, Parkhurst KL, Matsumoto AH. Use of a Commercially Available Clinical Decision Support Tool to Expedite Prior Authorization in Partnership With a Private Payer. J Am Coll Radiol 2021; 18:857-863. [PMID: 33516767 DOI: 10.1016/j.jacr.2021.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 08/06/2020] [Accepted: 01/14/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE The aim of this study was to determine if a clinical decision support (CDS) tool could be used in partnership with a private payer to successfully expedite the prior authorization process for advanced (ie, MRI, CT, PET, nuclear medicine) imaging requests. METHODS A single academic institution integrated a commercially available CDS tool utilizing the ACR Appropriateness Criteria into the ordering process for outpatient advanced imaging tests within the electronic health record. Ordering providers could elect to use the CDS tool or ignore the available technology. In partnership with a health care insurance company and a contracted radiology benefits management company, orders deemed as "usually indicated" by the CDS tool underwent expedited prior authorization in a pilot program from June 2018 to October 2019. RESULTS Providers used the CDS tool for 15% (1,453 of 9,640) of outpatient advanced imaging orders. Of these orders with elective CDS scores, 69% (n = 997) qualified for an expedited prior authorization process. CONCLUSIONS Under specific circumstances, a commercially available CDS tool was used in partnership with a private payer and a radiology benefits management company to expedite prior authorization of outpatient advanced imaging examination orders deemed likely to be appropriate by multispecialty professional guidelines.
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Affiliation(s)
- Cree M Gaskin
- Vice Chair of Clinical Operations and Informatics, Division Chief of Musculoskeletal Imaging and Intervention, and Associate Chief Medical Information Officer, Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia.
| | - Amy L Ellenbogen
- Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
| | - Kristi L Parkhurst
- Business Office Manager, Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
| | - Alan H Matsumoto
- Chair of the Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
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Mackie TI, Schaefer AJ, Karpman HE, Lee SM, Bellonci C, Larson J. Systematic Review: System-wide Interventions to Monitor Pediatric Antipsychotic Prescribing and Promote Best Practice. J Am Acad Child Adolesc Psychiatry 2021; 60:76-104.e7. [PMID: 32966838 DOI: 10.1016/j.jaac.2020.08.441] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 08/04/2020] [Accepted: 09/14/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Rapid growth of antipsychotic use among children and adolescents at the turn of the 21st century led Medicaid programs to implement 3 types of system-wide interventions: antipsychotic monitoring programs, clinician prescribing supports, and delivery system enhancements. This systematic review assessed the available evidence base for and relative merits of these system-wide interventions that aim to improve antipsychotic treatment and management. METHOD Using PRISMA guidelines, eligible studies were written in English and evaluated system-wide interventions to monitor antipsychotic treatment or promote antipsychotic management among children and adolescents (0-21 years of age). Studies were identified through Ovid MEDLINE and PsychInfo (years 1990-2018) and an environmental scan. From an initial review of 824 publications, 17 studies met eligibility criteria. Two authors independently conducted quality assessments using the Crowe Critical Appraisal Tool. Findings were summarized descriptively. RESULTS Identified studies (n = 17) evaluated prior authorization programs (n = 10), drug utilization reviews (n = 2), quality improvement (n = 4), care coordination programs (n = 1), and multimodal initiatives (n = 2). Studies were predominantly pre-post analyses, without a comparison group. With the exception of care coordination and drug utilization reviews, more than half of the interventions in each category were associated with significant reduction in antipsychotic treatment or promotion of best practice parameters. CONCLUSION This evidence review concludes that evaluations of prior authorization programs demonstrate reductions in antipsychotic treatment, though evidence of impact of other system-wide interventions and other outcomes is limited. Additional research is necessary to investigate whether interventions influenced antipsychotic prescribing independent of secular trends, the comparative effectiveness and cost-effectiveness of interventions, the effect on functional outcomes, and the potential for unintended consequences.
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Affiliation(s)
- Thomas I Mackie
- Rutgers School of Public Health and Institute for Health, Health Care Policy, and Aging Research, at Rutgers, the State University of New Jersey, New Brunswick.
| | - Ana J Schaefer
- Rutgers School of Public Health and Institute for Health, Health Care Policy, and Aging Research, at Rutgers, the State University of New Jersey, New Brunswick
| | | | - Stacey M Lee
- Health Resources and Services Administration, Rockville, Maryland; Substance Abuse and Mental Health Services Administration, Rockville, Maryland
| | - Christopher Bellonci
- Judge Baker Children's Center, Boston, Massachusetts, and Harvard Medical School, Boston, Massachusetts
| | - Justine Larson
- Substance Abuse and Mental Health Services Administration, Rockville, Maryland
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Torrecillas VF, Neuberger K, Ramirez A, Krakovitz P, Meier JD. What Is the Impact of Prior Authorization on the Incidence of Pediatric Tonsillectomy? Otolaryngol Head Neck Surg 2020; 164:1193-1199. [PMID: 33170763 DOI: 10.1177/0194599820969631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Third-party payers advocate for prior authorization (PA) to reduce overutilization of health care resources. The impact of PA in elective surgery is understudied, especially in cases where evidence-based clinical practice guidelines define operative candidacy. The objective of this study is to investigate the impact of PA on the incidence of pediatric tonsillectomy. STUDY DESIGN Cross-sectional study. SETTING Health claims database from a third-party payer. METHODS Any pediatric patient who had evaluation for tonsillectomy from 2016 to 2019 was eligible for inclusion. A time series analysis was used to evaluate the change in incidence of tonsillectomy before and after PA. Lag time from consultation to surgery before and after PA was compared with segmented regression. RESULTS A total of 10,047 tonsillectomy claims met inclusion and exclusion criteria. Female patients made up 51% of claims, and the mean age was 7.9 years. Just 1.5% of claims were denied after PA implementation. There was no change in the incidence of tonsillectomy for all plan types (P = .1). Increased lag time from consultation to surgery was noted immediately after PA implementation by 2.38 days (95% CI, 0.23-4.54; P = .030); otherwise, there was no significant change over time (P = .98). CONCLUSION A modest number of tonsillectomy claims were denied approval after implementation of PA. The value of PA for pediatric tonsillectomy is questionable, as it did not result in decreased incidence of tonsillectomy in this cohort.
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Affiliation(s)
| | - Kaden Neuberger
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Paul Krakovitz
- Department of Otolaryngology, University of Utah, Salt Lake City, Utah, USA
| | - Jeremy D Meier
- Department of Otolaryngology, University of Utah, Salt Lake City, Utah, USA
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DaCosta Byfield S, Chastek B, Korrer S, Horstman T, Malin J, Newcomer L. Real-World Outcomes and Value of First-Line Therapy for Metastatic Non-Small Cell Lung Cancer †. Cancer Invest 2020; 38:608-617. [PMID: 33107767 DOI: 10.1080/07357907.2020.1827415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Although physicians rely on clinical trial data to guide cancer treatment decisions, patient characteristics and outcomes often differ between real-world and clinical trial populations. We analyzed retrospective clinical data collected from a prior authorization (PA) tool linked with payer claims data to describe outcomes of first-line treatment for metastatic non-small cell lung cancer among 2,108 patients. Duration of therapy was shorter than observed in clinical trials. Healthcare costs and hospitalizations varied substantially by regimen. PA clinical data linked with administrative claims enable head-to-head comparisons of contemporary cancer treatments used in routine clinical practice, which are not available from clinical trials.
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Affiliation(s)
| | | | | | | | | | - Lee Newcomer
- Lee N. Newcomer Consulting, LLC, Minneapolis, Minnesota, USA
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35
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Psotka MA, Fiuzat M, Solomon SD, Chauhan C, Felker GM, Butler J, Teerlink JR, Sinha SS, O'Connor CM, Konstam MA. Challenges and Potential Improvements to Patient Access to Pharmaceuticals: Examples From Cardiology. Circulation 2020; 142:790-798. [PMID: 32833519 DOI: 10.1161/circulationaha.119.044976] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Patient access to a drug after US regulatory approval is controlled by complex interactions between governmental and third-party payers, pharmacy benefit managers, distributers, manufacturers, health systems, and pharmacies that together mediate the receipt of goods by patients after prescription by clinicians. Recent medication approvals highlight why and how the distribution of clinically beneficial novel therapies is controlled. Although imposed limitations on availability may be rational considering the fiduciary responsibilities of payers and escalating spending on health care and pharmaceuticals, transparency and communication are lacking, and some utilization management may disproportionately affect vulnerable populations. Analysis of the current health insurance landscape suggests mechanisms by which patient access to appropriate medications can be improved and patient and clinician frustration reduced while acknowledging the financial realities of the pharmaceutical marketplace. We propose creation of a shared, standardized, and transparent process for coverage decisions that minimizes administrative barriers and is defensible on the basis of clinical and cost-effectiveness evidence. These reforms would benefit patients and improve the efficiency of the pharmaceutical system.
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Affiliation(s)
- Mitchell A Psotka
- Inova Heart & Vascular Institute, Falls Church, VA (M.A.P., S.S.S., C.M.O.)
| | - Mona Fiuzat
- Department of Medicine, Duke University School of Medicine, Durham, NC (M.F.)
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S.)
| | | | - G Michael Felker
- Division of Cardiology, Duke University Medical Center, Durham, NC (G.M.F.)
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson (J.B.)
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco (J.R.T.)
| | - Shashank S Sinha
- Inova Heart & Vascular Institute, Falls Church, VA (M.A.P., S.S.S., C.M.O.)
| | | | - Marvin A Konstam
- The CardioVascular Center of Tufts Medical Center, Boston, MA (M.A.K.)
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Affiliation(s)
- Eugene Yang
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
| | - Sushan Yang
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
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Akincigil A, Mackie TI, Cook S, Hilt RJ, Crystal S. Effectiveness of mandatory peer review to reduce antipsychotic prescriptions for Medicaid-insured children. Health Serv Res 2020; 55:596-603. [PMID: 32567089 DOI: 10.1111/1475-6773.13297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Prior authorization of prescription medications is a policy tool that can potentially impact care quality and patient safety. OBJECTIVE To examine the effectiveness of a mandatory peer-review program in reducing antipsychotic prescriptions among Medicaid-insured children, accounting for secular trends that affected antipsychotic prescribing nationally. DATA SOURCE Medicaid Analytical eXtracts (MAX) with administrative claims for health services provided between January 2006 and December 2011. STUDY DESIGN This retrospective, observational study examined prescription claims records from Washington State (Washington) and compared them to a synthetic control drawing from 20 potential donor states that had not implemented any antipsychotic prior authorization program or mandatory peer review for Medicaid-insured children during the study period. This method provided a means to control for secular trends by simulating the antipsychotic use trajectory that the program state would have been expected to experience in the absence of the policy implementation. PRINCIPAL FINDINGS Before the policy implementation, antipsychotic use prevalence closely tracked those of the synthetic control (6.17 per 1000 in Washington vs. 6.21 in the synthetic control group). Within two years after the policy was implemented, prevalence decreased to 4.04 in Washington and remained stable in the synthetic control group (6.47), corresponding to an approximately 38% decline. CONCLUSION Prior authorization program designs and implementations vary widely. This mandatory peer-review program, with an authorization window and two-stage rollout, was effective in moving population level statistics toward safe and judicious use of antipsychotic medications in children.
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Affiliation(s)
- Ayse Akincigil
- School of Social Work, Rutgers, The State University of New Jersey, New Brunswick, New Jersey.,Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey
| | - Thomas I Mackie
- Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey.,School of Public Health, Rutgers, The State University of New Jersey, Piscataway, New Jersey
| | - Sharon Cook
- Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey
| | - Robert J Hilt
- Psychiatry and Behavioral Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey
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Spence O, Reeves G, dosReis S. Spillover effects of state medicaid antipsychotic prior authorization policies in US commercially insured youth. Pharmacoepidemiol Drug Saf 2020; 29:1064-1071. [PMID: 32558177 DOI: 10.1002/pds.5032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 04/10/2020] [Accepted: 05/04/2020] [Indexed: 11/06/2022]
Abstract
PURPOSE To evaluate spillover effects of Medicaid antipsychotic prior authorization (PA) policies among commercially insured youth. METHODS Commercially insured youth residing in nine US states that implemented PA exclusively for antipsychotics in 2011 or 2012 were identified using a 10% random sample of enrollees in the IQVIA PharMetrics Plus database spanning 2007 to 2015. Youth were included if they were ≤18 years, met the age criteria of the PA at the time of dispensing, and had at least 1 month of prescription drug coverage from 2007 to 2015. The primary outcome of interest was the monthly prevalence of antipsychotics. We implemented segmented regression of interrupted time series analysis to estimate changes in the monthly prevalence of targeted medications, overall and stratified by age. Trends were compared in the 4-year period before and the 3-year period after implementation of PA policies. RESULTS Antipsychotics prescribing significantly decreased 6.74/10 000 (95% CI, -9.04 to -4.44) enrollees per month immediately after PA implementation. However, PA was not associated with significant long-term trend changes (-0.06; 95% CI, -0.16 to 0.03). Antipsychotic prescribing in children <12 years-old significantly decreased 0.14/10 000 (95% CI, -0.21 to -0.07) enrollees per month after PA implementation, while prescribing in adolescents 12 to 18 years-old significantly increased 0.32/10 000 (95% CI, 0.16 to 0.47) enrollees per month. CONCLUSION While Medicaid PA polices for antipsychotic oversight did not affect overall prescribing, there were spillover effects in U.S. commercially insured children <12 years-old. This suggests that state-level Medicaid policies intended to improve the quality of care and safe use of antipsychotics can have broad reach.
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Affiliation(s)
- O'Mareen Spence
- Pharmaceutical Health Services Research Department, University of Maryland Baltimore, School of Pharmacy, Baltimore, Maryland, USA
| | - Gloria Reeves
- Division of Child and Adolescent Psychiatry, University of Maryland Baltimore, School of Medicine, Baltimore, Maryland, USA
| | - Susan dosReis
- Pharmaceutical Health Services Research Department, University of Maryland Baltimore, School of Pharmacy, Baltimore, Maryland, USA
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Jain VD, Bsat FA, Ruma MS, Sciscione AC, Iriye BK. Prior authorization and its impact on access to obstetric ultrasound. Am J Obstet Gynecol 2020; 222:338.e1-338.e5. [PMID: 31962106 DOI: 10.1016/j.ajog.2020.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 11/30/2022]
Abstract
Prior authorization is a process requiring health care providers to obtain advance approval from a payer before a patient undergoes a procedure for the study to be covered. Prior authorization was introduced to decrease overutilization of ultrasound procedures. However, it has led to unanticipated consequences such as impeding access to obstetric imaging, increased administrative overhead without reimbursement, and contribution to physician frustration and burnout. Payers often use intermediary radiology benefit management companies without providing specialty-specific review in a timely manner as is requisite when practicing high-risk obstetrics. This article proposes a number of potential solutions to this problem: (1) consider alternative means to monitor overutilization; (2) create and evaluate data regarding providers in the highest utilization; (3) continue to support and grow the educational efforts of speciality societies to publish clinical guidelines; and (4) emphasize the importance of practicing evidence-based medicine. Understanding that not all health plans may be willing or able to collaborate with health care providers, we encourage physicians to advocate for policies and legislation to limit the implementation of prior authorization within their own states.
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Affiliation(s)
- Vanita D Jain
- Delaware Center for Maternal-Fetal Medicine of Christiana Care, Inc, Newark, DE.
| | - Fadi A Bsat
- Department of Obstetrics and Gynecology, University of Massachusetts Medical School-Baystate, Springfield, MA
| | | | - Anthony C Sciscione
- Delaware Center for Maternal-Fetal Medicine of Christiana Care, Inc, Newark, DE
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Doshi JA, Li P, Puckett JT, Pettit AR, Raman S, Parmacek MS, Rader DJ. Trends and Factors Associated With Insurer Approval of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor Prescriptions. Value Health 2020; 23:209-216. [PMID: 32113626 DOI: 10.1016/j.jval.2019.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/29/2019] [Accepted: 08/05/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9is)-innovative yet costly cholesterol-lowering agents-have been subject to substantial prior authorization (PA) requirements and low approval rates. We aimed to investigate trends in insurer approval and reasons for rejection for PCSK9i prescriptions as well as associations between patients' demographic, clinical, pharmacy, payer, and PCSK9i-specific plan/coverage factors and approval. METHODS We examined trends in PCSK9i approval rates and reasons for rejection using medical and prescription claims from 2015 to 2017 for individuals who received a PCSK9i prescription. We used multinomial logistic regression to estimate quarterly risk-adjusted approval rates for initial PCSK9i prescriptions and approval for any PCSK9i prescription within 30, 90, and 180 days of the initial PCSK9i prescription. For a 2016 subsample for whom we had PCSK9i-specific plan policy data, we examined factors associated with approval including PCSK9i-specific plan formulary coverage, step therapy requirements, and number of PA criteria. RESULTS The main sample included 12 309 patients (mean age 64.8 years [SD = 10.8], 52.1% female, 51.5% receiving Medicare) and was similar in characteristics to the 2016 subsample (n = 6091). Approval rates varied across quarters but remained low (initial prescription, 13%-23%; within 90 days, 28%-44%). Over time, rejections owing to a lack of formulary coverage decreased and rejections owing to PA requirements increased. Lack of formulary coverage and having ≥11 PA criteria in the plan policy were associated with lower odds of PCSK9i prescription approval. CONCLUSIONS These findings confirm ongoing PCSK9i access issues and offer a baseline for comparison in future studies examining the impact of recent efforts to improve PCSK9i access.
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Affiliation(s)
- Jalpa A Doshi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Pengxiang Li
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Justin T Puckett
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amy R Pettit
- Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA, USA
| | - Swathi Raman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael S Parmacek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel J Rader
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Jones LK, Ladd IG, Gregor C, Evans MA, Graham J, Gionfriddo MR. Understanding the medication prior-authorization process: A case study of patients and clinical staff from a large rural integrated health delivery system. Am J Health Syst Pharm 2020; 76:453-459. [PMID: 31361821 DOI: 10.1093/ajhp/zxy083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The barriers and solutions to the current prior-authorization (PA) process at an integrated health system were evaluated. METHODS Focus groups were conducted with patients at an integrated health system who also had insurance from an affiliated health plan and at least 1 denial for a medication in the past year. Semistructured interviews were conducted with medical staff (physicians, office staff, and PA experts). Both focus groups and interviews were audio-recorded and transcribed. Inductive analysis was used to code transcripts and develop themes. RESULTS Three focus groups were conducted with 13 patients, and 9 medical staff (3 staff physicians, 2 office staff, and 4 PA staff) who have interactions with the PA process interviewed. Several themes were identified including the complexity of the PA process, consequences experienced, and ineffective communication between key stakeholders. A cross-cutting theme was that stakeholders expressed feelings of frustration, anxiety, and anger throughout the PA process. All stakeholders offered insights on how the process could be improved to better facilitate their preferences, such as access to the list of medications that require PA and the need for a patient advocate. CONCLUSION Results of this study revealed that the PA process was frustrating, upsetting, and infuriating to patients and medical staff involved in the process. Three main themes identified included the complexity of the PA process, consequences experienced from the PA process, and ineffective communication between stakeholders.
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Affiliation(s)
- Laney K Jones
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | - Ilene G Ladd
- Genomic Medicine Institute, Geisinger, Danville, PA
| | - Christina Gregor
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | | | - Jove Graham
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
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Campbell D, Blazer M, Bloudek L, Brokars J, Makenbaeva D. Realized and Projected Cost-Savings from the Introduction of Generic Imatinib Through Formulary Management in Patients with Chronic Myelogenous Leukemia. Am Health Drug Benefits 2019; 12:333-342. [PMID: 32055281 PMCID: PMC6996618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/19/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Imatinib, a first-generation tyrosine kinase inhibitor (TKI), and the newer second-generation TKIs have dramatically improved outcomes for patients with chronic myelogenous leukemia (CML). A previous model estimated the potential cost-savings over the next 2 years after the loss of patent exclusivity for imatinib in the United States in 2016 and its availability in a generic form. Payers have indeed realized meaningful savings, but it took 2 years for the prices of generic imatinib to decline substantially. OBJECTIVE To quantify the cost-savings for a US health plan from the passive substitution of generic imatinib and the impact of step-edit therapy with the use of generic imatinib before coverage of a second-generation TKI. METHODS We updated the previously published model utilizing hypothetical 1-million-member commercial and Medicare plans to include current TKI use and pricing combined with recent epidemiologic data. Regression models were used to project utilization to 5 years after the loss of imatinib's patent exclusivity. We compared generic imatinib costs with a scenario in which generic imatinib was not available. The impact of a step-edit therapy restriction was explored for patients with incident CML. The analyses were repeated for the entire US population based on national census data. RESULTS The 1-million-member commercial plan saved $0.5 million (3%) from pharmacy spending on TKIs in year 1 and $3.9 million (19%) in year 2 after the loss of patent exclusivity. The projected savings significantly increased to $7.8 million (37%), $8.3 million (39%), and $8.6 million (40%) in years 3, 4, and 5, respectively. Step-edits strategies were projected to result in small incremental savings of $0.3 million (1.5%) annually in years 3 to 5. The 1-million-member Medicare plan saved $1.7 million (3%) in year 1 and $14.1 million (19%) in year 2. The projected savings were $27.8 million (37%), $29.5 million (39%), and $30.8 million (40%), with step-edit estimated to add only $0.9 million (1.2%) annually in years 3 to 5. Generic imatinib saved US payers $2.5 billion (13% of the total spending on TKIs) in years 1 and 2. In years 3 to 5, the cumulative projected savings totaled $12.2 billion, and the savings were expected to grow to 39% as a result of passive generic imatinib substitution, with only 1.7% additional savings from step-edit restriction. CONCLUSIONS As a result of a lower price for generic imatinib relative to the brand-name version of the drug, substantial cost-savings to US payers over the next 3 years are expected without step-edit formulary management restrictions. Cost-saving strategies, including formulary management restrictions, should adhere to evidence-based guidelines to ensure the appropriate use of generic imatinib and all available TKIs, with the objective to maintain positive outcomes and, in turn, increase the value of patient care.
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Affiliation(s)
- David Campbell
- Assistant Director, Scientific Consulting, Scientific Consulting, Xcenda, Palm Harbor, FL
| | - Marlo Blazer
- Associate Director, Scientific Consulting, Xcenda, Palm Harbor, FL
| | | | - John Brokars
- Health Outcomes Research Director, Worldwide Health Economics and Outcomes Research Communications Lead, Bristol-Myers Squibb, Princeton, NJ
| | - Dinara Makenbaeva
- Group Director, Worldwide Health Economics and Outcomes Research Communications Lead, Bristol-Myers Squibb, Princeton, NJ
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Abstract
OBJECTIVE To understand differences in patient demographics, insurance-related treatment delays, and average waiting times for Medicare and private insurance patients undergoing upper airway stimulation (UAS) for treatment of obstructive sleep apnea (OSA). METHODS Retrospective chart review of all Medicare and private insurance patients undergoing upper airway stimulation (UAS) from 2015 to 2018 at a single academic center. Primary outcomes were insurance-related procedure cancellation rate and time from drug induced sleep endoscopy (DISE) and UAS treatment recommendation to UAS surgery in Medicare versus private insurance patients. RESULTS In our cohort 207 underwent DISE and were recommended treatment with UAS. Forty-four patients with Medicare and 30 patients with private insurance underwent UAS procedure. Patients with Medicare undergoing UAS were older (67.4 ± 11.1 years) than patients with private insurance (54.9 ± 8.1 years). Medicare patients had a shorter mean wait time of 121.9 ± 75.8 days (range, 15-331 days) from the time of UAS treatment recommendation to UAS surgery when compared to patients with private insurance (201.3 ± 102.2 days; range, 33-477 days). Three patients with Medicare (6.4%) and 8 patients with private insurance (21.1%) were ultimately denied UAS. CONCLUSION Medicare patients undergoing UAS have shorter waiting periods, fewer insurance-related treatment delays and may experience fewer procedure cancellations when compared to patients with private insurance. The investigational status of UAS by private insurance companies delays care for patients with OSA. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Jena Patel
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael C Topf
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Bhat S, Zahorian T, Robert R, Farraye FA. Advocating for Patients With Inflammatory Bowel Disease: How to Navigate the Prior Authorization Process. Inflamm Bowel Dis 2019; 25:1621-1628. [PMID: 30753551 DOI: 10.1093/ibd/izz013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/22/2019] [Indexed: 12/09/2022]
Abstract
In an effort to manage health care costs and avoid improper medication use, prior authorizations (PAs) have become a standard stipulation required by payers in the determination of medication coverage. For gastroenterologists managing patients, especially those with inflammatory bowel disease (IBD), the PA process is time-consuming and further complicated by 2 additional factors: step therapy requirements and failure of payers to recognize updated IBD treatment pathways. These factors often lead to PA denials and cause treatment delays, which in turn can lead to disease progression, ongoing patient suffering, and ultimately an increase in both direct and indirect total costs. In this manuscript, the PA process, PA models, tips and available resources to navigate the PA process, and future advocacy efforts are discussed with the intent to help gastroenterology practices optimize PA outcomes and improve the care provided to patients with IBD and other gastrointestinal disorders.
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Affiliation(s)
- Shubha Bhat
- Center for Digestive Disorders, Boston Medical Center, Boston, Massachusetts
| | - Toni Zahorian
- Center for Digestive Disorders, Boston Medical Center, Boston, Massachusetts
| | - Regine Robert
- Center for Digestive Disorders, Boston Medical Center, Boston, Massachusetts
| | - Francis A Farraye
- Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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Franklin GM, Mercier M, Mai J, Tuman D, Fulton-Kehoe D, Wickizer T, Sears JM. Brief report: Population-based reversal of the adverse impact of opioids on disability in Washington State workers' compensation. Am J Ind Med 2019; 62:168-174. [PMID: 30592542 DOI: 10.1002/ajim.22937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2018] [Indexed: 11/12/2022]
Abstract
BACKGROUND Evidence has associated opioid use initiated early in a workers' compensation claim with subsequent disability. In 2013, the Washington State Department of Labor and Industries (DLI) implemented procedures based on new regulations that require improvement in pain and function to approve opioids beyond the acute pain period. METHODS We measured opioid prescriptions between 6 and 12 weeks following injury, an indicator of persistent opioid use. Actuarial data for the association of any opioid use versus no opioid use with development of lost time payments are reported. RESULTS Prior authorization with hard stops led to a sustained drop in persistent opioid use, from nearly 5% in 2013 to less than 1% in 2017. This reduction was also associated with reversal of the increased lost work time patterns seen from 1999 to 2010. CONCLUSIONS Prior authorization targeted at preventing transition to chronic opioid use can prevent and reverse adverse time loss development that has occurred on a population basis concomitant with the opioid epidemic.
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Affiliation(s)
- Gary M. Franklin
- Washington State Department of Labor and Industries; Olympia Washington
- Department of Environmental and Occupational Health Sciences; University of Washington; Seattle Washington
- Department of Health Services; University of Washington; Seattle Washington
- Department of Neurology; University of Washington; Seattle Washington
| | - Mark Mercier
- Washington State Department of Labor and Industries; Olympia Washington
| | - Jaymie Mai
- Washington State Department of Labor and Industries; Olympia Washington
| | - Doug Tuman
- Washington State Department of Labor and Industries; Olympia Washington
| | - Deborah Fulton-Kehoe
- Department of Environmental and Occupational Health Sciences; University of Washington; Seattle Washington
| | - Thomas Wickizer
- Division of Health Services Management and Policy; The Ohio State University College of Public Health; Columbus Ohio
| | - Jeanne M. Sears
- Department of Health Services; University of Washington; Seattle Washington
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McLaughlin M, Kalfayan N, Grant J, Hawkins C, Cottreau J, Palella FJ, Stosor V. Time Requirements for Acquisition of Hepatitis C Virus Therapy in HIV/HCV Coinfected Patients. J Pharm Technol 2018; 34:149-152. [PMID: 34860986 PMCID: PMC6041866 DOI: 10.1177/8755122518770431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023] Open
Abstract
Background: The process of obtaining approval for hepatitis C virus (HCV) treatment may be time consuming and complicated due to prior authorizations and the need to appeal denials. Pharmacists are poised to play a critical role in the acquisition and management of oral direct acting antivirals (DAAs) for the treatment of HCV infection; however, the time expended in this activity requires assessment. Objective: The objective of this study was to assess time expenditures by pharmacists to acquire DAAs for HCV therapy. Methods: Patients were enrolled in the Northwestern University Viral Hepatitis Registry, a prospective, observational cohort of ambulatory, adult patients living with human immunodeficiency virus (HIV) coinfected with chronic hepatitis B and/or C virus, and recruited since 2013 from the Infectious Disease Center at Northwestern Memorial Hospital, Chicago, IL. Patients were included in the current study if they were referred to the pharmacist for HCV DAA acquisition, drug-drug interaction management, and adherence counseling between February 1, 2014, and April 30, 2015. Patient demographics, virus-specific characteristics, and time required to secure HCV DAA treatment, counsel patients, and follow-up therapy were collected. Results: Among 54 HIV/HCV coinfected patients referred for treatment, all eventually received approval for DAA therapy. However, 87% (n = 47) required prior authorization. Pharmacists dedicated 2.1 hours/patient (interquartile range 1.5-2.8 hours; range 0.75-6.5 hours) to manage DAA therapy. Conclusion: Successful acquisition of HCV DAA therapy relied heavily on pharmacist effort, reflecting the vital role that pharmacists play in this process. Dedicated resources for medication access should be considered to ensure timely DAA acquisition.
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Affiliation(s)
- Milena McLaughlin
- Midwestern University, Downers Grove,
IL, USA
- Northwestern Memorial Hospital, Chicago,
IL, USA
| | | | | | | | - Jessica Cottreau
- Northwestern Memorial Hospital, Chicago,
IL, USA
- Rosalind Franklin University of Medicine
and Science, North Chicago, IL, USA
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Powell AC, Price SE, Nguyen K, Smith GL, Long JW, Deshmukh UU. Prior Authorization for Elective Diagnostic Catheterization: The Value of Reviewers in Cases with Clinical Ambiguity. Am Health Drug Benefits 2018; 11:168-176. [PMID: 30464785 PMCID: PMC6207309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/05/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND In many situations, evidence-based guidelines cannot provide definitive guidance on the appropriateness of diagnostic catheterization. One specialty benefit management company has taken a 2-step approach to address this ambiguity by evaluating the appropriateness of diagnostic catheterization orders using a rule-based decision support system, and then having reviewers provide input through the consult system of a nondenial prior authorization program that involves peer discussion. OBJECTIVE To describe the outcomes of a 2-step approach to evaluating the appropriateness of elective diagnostic catheterization orders. METHOD This program evaluation used data from elective diagnostic catheterization orders from 2015 that pertained to 1 health insurer's Medicare Advantage plans. The classifications of orders by the rule-based system and the approval rates after review by the consult system are presented for these plans. Chi-square tests were conducted to examine whether classifications of the orders by the rule-based and consult systems were independent of plan type, specialty of the ordering physician, or state of residence of the patient. RESULTS A total of 3808 orders for elective diagnostic catheterization in 2015 met the inclusion criteria. Inadequate initial justification was provided for 699 (18.4%) of the orders; after inquiry through the consult system, 509 (72.8%) of the remaining orders were approved. Among the 344 (9%) orders that were deemed potentially nonindicated according to the rule-based system, the consult system approved 298 (86.6%). Of the 2765 (72.6%) orders that were deemed potentially appropriate by the rule-based system, the consult system approved 2740 (99.1%). Chi-square tests did not show a significant association between plan type or physician specialty and the classification produced by the rule-based system or the consult system. The patients' state of residence was significantly associated with the classification of orders for the rule-based system (P <.001), but not for the consult system. CONCLUSION Rule-based decision support can be combined with consult-based peer discussion to determine whether care is appropriate when guidelines are ambiguous. Poorly justified orders are often supportable after gathering information on the patient's presentation.
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Affiliation(s)
- Adam C Powell
- Director, Outcomes Research, HealthHelp, Houston, TX
| | - Stephen E Price
- Consultant, Clinical Vendor Oversight and Trend Management, Humana, Louisville, KY
| | - Khoa Nguyen
- Analyst, Medical Economics & Informatics, HealthHelp
| | - Gary L Smith
- Vice President, Medical Economics & Informatics, HealthHelp
| | - James W Long
- Director, Clinical Vendor Oversight and Trend Management, Humana
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Dunn EE, Vranek K, Hynicka LM, Gripshover J, Potosky D, Mattingly TJ. Evaluating a Collaborative Approach to Improve Prior Authorization Efficiency in the Treatment of Hepatitis C Virus. Qual Manag Health Care 2018; 26:136-139. [PMID: 28665904 PMCID: PMC5499965 DOI: 10.1097/qmh.0000000000000137] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE A team-based approach to obtaining prior authorization approval was implemented utilizing a specialty pharmacy, a clinic-based pharmacy technician specialist, and a registered nurse to work with providers to obtain approval for medications for hepatitis C virus (HCV) infection. The objective of this study was to evaluate the time to approval for prescribed treatment of HCV infection. METHODS A retrospective observational study was conducted including patients treated for HCV infection by clinic providers who received at least 1 oral direct-acting antiviral HCV medication. Patients were divided into 2 groups, based on whether they were treated before or after the implementation of the team-based approach. Student t tests were used to compare average wait times before and after the intervention. RESULTS The sample included 180 patients, 68 treated before the intervention and 112 patients who initiated therapy after. All patients sampled required prior authorization approval by a third-party payer to begin therapy. There was a statistically significant reduction (P = .02) in average wait time in the postintervention group (15.6 ± 12.1 days) once adjusted using dates of approval. CONCLUSIONS Pharmacy collaboration may provide increases in efficiency in provider prior authorization practices and reduced wait time for patients to begin treatment.
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Affiliation(s)
- Emily E. Dunn
- University of Maryland School of Pharmacy, Baltimore (Dr Dunn); Ambulatory Pharmacy, University of Maryland Medical Center, Baltimore (Dr Vranek); Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore (Drs Hynicka and Mattingly II); and Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore (Ms Gripshover and Dr Potosky)
| | - Kathryn Vranek
- University of Maryland School of Pharmacy, Baltimore (Dr Dunn); Ambulatory Pharmacy, University of Maryland Medical Center, Baltimore (Dr Vranek); Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore (Drs Hynicka and Mattingly II); and Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore (Ms Gripshover and Dr Potosky)
| | - Lauren M. Hynicka
- University of Maryland School of Pharmacy, Baltimore (Dr Dunn); Ambulatory Pharmacy, University of Maryland Medical Center, Baltimore (Dr Vranek); Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore (Drs Hynicka and Mattingly II); and Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore (Ms Gripshover and Dr Potosky)
| | - Janet Gripshover
- University of Maryland School of Pharmacy, Baltimore (Dr Dunn); Ambulatory Pharmacy, University of Maryland Medical Center, Baltimore (Dr Vranek); Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore (Drs Hynicka and Mattingly II); and Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore (Ms Gripshover and Dr Potosky)
| | - Darryn Potosky
- University of Maryland School of Pharmacy, Baltimore (Dr Dunn); Ambulatory Pharmacy, University of Maryland Medical Center, Baltimore (Dr Vranek); Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore (Drs Hynicka and Mattingly II); and Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore (Ms Gripshover and Dr Potosky)
| | - T. Joseph Mattingly
- University of Maryland School of Pharmacy, Baltimore (Dr Dunn); Ambulatory Pharmacy, University of Maryland Medical Center, Baltimore (Dr Vranek); Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore (Drs Hynicka and Mattingly II); and Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore (Ms Gripshover and Dr Potosky)
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Hartung DM, Kim H, Ahmed SM, Middleton L, Keast S, Deyo RA, Zhang K, McConnell KJ. Effect of a high dosage opioid prior authorization policy on prescription opioid use, misuse, and overdose outcomes. Subst Abus 2018; 39:239-246. [PMID: 29016245 PMCID: PMC9926935 DOI: 10.1080/08897077.2017.1389798] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND High dosage opioid use is a risk factor for opioid-related overdose commonly cited in guidelines, recommendations, and policies. In 2012, the Oregon Medicaid program developed a prior authorization policy for opioid prescriptions above 120 mg per day morphine equivalent dose (MED). This study aimed to evaluate the effects of that policy on utilization, prescribing patterns, and health outcomes. METHODS Using administrative claims data from Oregon and a control state (Colorado) between 2011 and 2013, we used difference-in-differences analyses to examine changes in utilization, measures of high risk opioid use, and overdose after introduction of the policy. We also evaluated opioid utilization in a cohort of individuals who were high dosage opioid users before the policy. RESULTS Following implementation of Oregon's high dosage policy, the monthly probability of an opioid fill over 120 mg MED declined significantly by 1.7 percentage points (95% confidence interval [CI]; -2.0% to -1.4%), whereas it increased significantly by 1.0 percentage points (95% CI 0.4% to 1.7%) for opioid fills < 61 mg MED. Fills of medications used to treat neuropathic pain also increased by 1.2 percentage points (95% CI 0.7% to 1.8%). The monthly probability of multiple pharmacy use declined by 0.1 percentage points (-0.2% to -0.0) following the prior authorization, but there were no significant changes in ED encounters or hospitalizations for opioid overdose. Among individuals who were using a high dosage opioid before the policy, there was a 20.3 percentage point (95% CI -15.3% to -25.3%) decline in estimated probability of having a high dosage fill after the policy. CONCLUSIONS Oregon's prior authorization policy was effective at reducing high dosage opioid prescriptions. While multiple pharmacy use also declined, we found no impact on opioid overdose were observed.
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Affiliation(s)
- Daniel M. Hartung
- Oregon State University/Oregon Health & Science University, College of Pharmacy, Portland, Oregon, USA
| | - Hyunjee Kim
- Oregon Health & Science University, Center for Health Systems Effectiveness, Portland, Oregon, USA
| | - Sharia M. Ahmed
- Oregon State University/Oregon Health & Science University, College of Pharmacy, Portland, Oregon, USA
| | - Luke Middleton
- Oregon State University/Oregon Health & Science University, College of Pharmacy, Portland, Oregon, USA
| | - Shellie Keast
- University of Oklahoma College of Pharmacy, Department of Clinical and Administrative Sciences, Oklahoma City, Oklahoma, USA
| | - Richard A. Deyo
- Oregon Health & Science University, Center for Health Systems Effectiveness, Portland, Oregon, USA
| | - Kun Zhang
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - K. John McConnell
- Oregon Health & Science University, Center for Health Systems Effectiveness, Portland, Oregon, USA
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50
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Jackson JW, Fulchino L, Rogers J, Mogun H, Polinski J, Henderson DC, Schneeweiss S, Fischer MA. "Impact of drug-reimbursement policies on prescribing: A case-study of a newly marketed long-acting injectable antipsychotic among relapsed schizophrenia patients". Pharmacoepidemiol Drug Saf 2017; 27:95-104. [PMID: 29168261 DOI: 10.1002/pds.4354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 10/17/2017] [Accepted: 10/18/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To quantify and explain variation in use of long-acting injectable antipsychotics (LAIs) in the United States, and understand the relationship between patient characteristics, drug reimbursement policies, and LAI prescribing after relapse. METHODS A cohort of recently relapsed patients with schizophrenia ages 18 to 64, were identified immediately after discharge from a related inpatient hospitalization, partial hospitalization, or emergency room visit, drawn from 2004 to 2006 Medicaid claims, and followed for 90 days until LAI initiation. Data on state-level Medicaid prior authorization (PA) policies for LAIs were collected. Sequential longitudinal Poisson regression models were developed to understand the relationship between patient and PA policy variables and LAI prescribing, including prior adherence to oral antipsychotics, demographics, clinical variables, and presence of PA policy for LAI. RESULTS Among 36 282 patients, 3.1% received risperidone LAI, and 3.8% received a first-generation (FGA) LAI with wide variation across states. Prior adherence ranged from 29% to 89% but was marginally associated with initiation and did not explain variation for LAI prescribing. FGA initiation was associated with geography and race/ethnicity but not PA policy. For risperidone LAI initiation, demographics and clinical factors explained, respectively, 5.0% and 3.0% of the variation; PA policy had a large negative association with initiation (RR = 0.41; 95%CI 0.20-0.87) and explained 8.4% of the variation. CONCLUSIONS PA policies may represent a major treatment barrier for risperidone LAI among relapsed patients. Non-adherence plays a little role in predicting which patients receive LAIs. Policy makers and health insurers will need to consider these findings when guiding the use of LAIs. KEY POINTS Among a nationwide cohort of relapsed schizophrenia patients enrolled in US Medicaid, 3.1% received Risperdal Consta, a long-acting injectable antipsychotic (LAI), and 3.8% initiated a first-generation first-generation LAI within 90 days after discharge. During 2004 to 2006, there was marked variation in 90 day post-relapse initiation of Risperdal-Consta-a newly marketed medication during this period-and also marked variation in 90 day post-relapse initiation of any first-generation LAI, which appeared to be associated with race/ethnicity and geography. Prior authorization policies were associated with substantially lower initiation of Risperdal Consta in this cohort of relapsed patients even after accounting for clinical indication (non-adherence), relapse history, demographics, adjunctive medication, and mental health service use.
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Affiliation(s)
- John W Jackson
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Schizophrenia Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Department of Epidemiology, Boston, MA, USA
| | - Lisa Fulchino
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - James Rogers
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jennifer Polinski
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,CVS Caremark Corporation, Woonsocket, RI, USA
| | - David C Henderson
- Schizophrenia Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Department of Epidemiology, Boston, MA, USA
| | - Michael A Fischer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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