Prada Sergio I
Dr Prada is Professor of Economics, Universidad Icesi, and Director, Center for Social Protection and Health Economics, Cali, Colombia.
Am Health Drug Benefits. 2017 Dec;10(9):477-482.
The Medicaid Drug Utilization Review (DUR) program is a 2-phase process conducted by Medicaid state agencies. The first phase is a prospective DUR and involves electronically monitoring prescription drug claims to identify prescription-related problems, such as therapeutic duplication, contraindications, incorrect dosage, or duration of treatment. The second phase is a retrospective DUR and involves ongoing and periodic examinations of claims data to identify patterns of fraud, abuse, underutilization, drug-drug interaction, or medically unnecessary care, implementing corrective actions when needed. The Centers for Medicare & Medicaid Services requires each state to measure prescription drug cost-savings generated from its DUR programs on an annual basis, but it provides no guidance or unified methodology for doing so.
To describe and synthesize the methodologies used by states to measure cost-savings using their Medicaid retrospective DUR program in federal fiscal years 2014 and 2015.
For each state, the cost-savings methodologies included in the Medicaid DUR 2014 and 2015 reports were downloaded from Medicaid's website. The reports were then reviewed and synthesized. Methods described by the states were classified according to research designs often described in evaluation textbooks.
In 2014, the most often used prescription drugs cost-savings estimation methodology for the Medicaid retrospective DUR program was a simple pre-post intervention method, without a comparison group (ie, 12 states). In 2015, the most common methodology used was a pre-post intervention method, with a comparison group (ie, 14 states). Comparisons of savings attributed to the program among states are still unreliable, because of a lack of a common methodology available for measuring cost-savings.
There is great variation among states in the methods used to measure prescription drug utilization cost-savings. This analysis suggests that there is still room for improvement in terms of methodology transparency, which is important, because lack of transparency hinders states from learning from each other. Ultimately, the federal government needs to evaluate and improve its DUR program.
医疗补助药物利用审查（DUR）计划是由医疗补助州机构进行的两阶段过程。第一阶段是前瞻性药物利用审查，涉及对处方药索赔进行电子监测，以识别与处方相关的问题，如治疗重复、禁忌症、剂量错误或治疗持续时间不当。第二阶段是回顾性药物利用审查，涉及对索赔数据进行持续和定期检查，以识别欺诈、滥用、利用不足、药物相互作用或医疗上不必要的护理模式，并在需要时采取纠正措施。医疗保险和医疗补助服务中心要求每个州每年衡量其药物利用审查计划产生的处方药成本节约情况，但未提供这样做的指导或统一方法。
描述和综合各州在2014财年和2015财年使用其医疗补助回顾性药物利用审查计划衡量成本节约所采用的方法。
对于每个州，从医疗补助网站下载了2014年和2015年医疗补助药物利用审查报告中包含的成本节约方法。然后对报告进行审查和综合。各州描述的方法根据评估教科书中经常描述的研究设计进行分类。
2014年，医疗补助回顾性药物利用审查计划最常用的处方药成本节约估计方法是简单的干预前后方法，没有对照组（即12个州）。2015年，最常用的方法是有对照组的干预前后方法（即14个州）。由于缺乏用于衡量成本节约的通用方法，各州之间归因于该计划的节约比较仍然不可靠。
各州在衡量处方药利用成本节约所使用的方法上存在很大差异。该分析表明，在方法透明度方面仍有改进空间，这很重要，因为缺乏透明度阻碍了各州相互学习。最终，联邦政府需要评估并改进其药物利用审查计划。
