Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
Med Care. 2010 Jan;48(1):4-9. doi: 10.1097/MLR.0b013e3181bd4c10.
Prior authorization policies (PA) are widely used to control psychotropic medication costs by state Medicaid programs and Medicare Part D plans. The objective of this study was to examine the impact of a Maine Medicaid PA policy on initiation and switching of anticonvulsant and atypical antipsychotic treatments among patients with bipolar disorder.
We obtained Maine and New Hampshire (comparison state) Medicaid and Medicare claims data for 2001 to 2004; the Maine PA policy was implemented in July 2003. Among continuously enrolled patients with bipolar disorder (Maine: n = 5336; New Hampshire: n = 1376), we used an interrupted times series with comparison group design to estimate changes in rates of initiating new episodes of bipolar treatment and generalized estimating equations models to examine rates of switching therapies among patients under treatment.
The Maine PA policy was associated with a marked decrease in rates of initiation of bipolar treatments; a relative reduction of 32.3% (95% CI: 24.8, 39.9) compared with expected rates at 4 months after policy implementation. This decrease was driven primarily by reductions in the initiation of nonpreferred agents. The policy had no discernable impact on rates of switching therapy among patients currently on treatment (RR: 1.03; 95% CI: 0.76, 1.39).
The findings of this study provide evidence that PA implementation can be a barrier to initiation of nonpreferred agents without offsetting increases in initiation of preferred agents, which is a major concern. There is a critical need to evaluate the possible unintended effects of PA policies to achieve optimal health outcomes among low-income patients with chronic mental illness. In addition, more research is needed to understand how these barriers arise and whether specific seriously mentally ill populations or drug classes should be exempted from PA policies.
先前授权政策（PA）被州医疗补助计划和医疗保险处方药计划广泛用于控制精神药物的费用。本研究的目的是检验缅因州医疗补助 PA 政策对双相情感障碍患者开始使用抗惊厥药和非典型抗精神病药以及换药的影响。
我们获得了缅因州和新罕布什尔州（对照州）2001 年至 2004 年的医疗补助和医疗保险索赔数据；缅因州的 PA 政策于 2003 年 7 月实施。在连续入组的双相情感障碍患者中（缅因州：n=5336；新罕布什尔州：n=1376），我们使用中断时间序列和对照组设计来估计新的双相治疗发作率的变化，并使用广义估计方程模型来检验治疗中患者的治疗转换率。
缅因州的 PA 政策与双相治疗开始率的显著下降相关；与政策实施后 4 个月的预期率相比，相对减少 32.3%（95%CI：24.8，39.9）。这种减少主要是由于非首选药物的起始减少。该政策对正在接受治疗的患者的治疗转换率没有明显影响（RR：1.03；95%CI：0.76，1.39）。
本研究结果提供了证据，表明 PA 的实施可能会成为非首选药物开始使用的障碍，而不会抵消首选药物开始使用的增加，这是一个主要问题。迫切需要评估 PA 政策的可能意外影响，以实现患有慢性精神疾病的低收入患者的最佳健康结果。此外，还需要更多的研究来了解这些障碍是如何产生的，以及是否应将某些严重的精神疾病患者或药物类别排除在 PA 政策之外。
