IMPAQ International LLC, Washington, District of Columbia.
IMPAQ International LLC, Columbia, Maryland.
JAMA Netw Open. 2020 Mar 2;3(3):e200274. doi: 10.1001/jamanetworkopen.2020.0274.
Although there are many pharmacologic alternatives to opioids, it is unclear whether the structure of Medicare Part D formularies discourages use of the alternatives.
To quantify the coverage of opioid alternatives and prevalence of prior authorization, step therapy, quantity limits, and tier placement for these drugs, and test whether these formulary exclusions and restrictions are associated with increased opioid prescribing to older adults at the county level.
DESIGN, SETTING, AND PARTICIPANTS: County fixed-effect models were estimated using a panel of counties across the 50 US states and the District of Columbia over calendar years 2015 and 2016. Data analysis was conducted from July 1 to September 23, 2019. The sample included 2721 counties in 2015 and 2671 counties in 2016 with sufficient data on Medicare Part D formulary design and opioid prescribing.
County-level opioid prescribing rate (number of opioid claims divided by the number of overall claims) and counts of excluded opioid alternatives and opioid alternatives with prior authorization, step therapy, quantity limits, and high-tier placements.
A total of 30 nonopioid analgesics were examined across 28 997 Medicare plans in 2015 and 30 390 plans in 2016. Medicare plans did not cover a mean of 7% of these drugs (interquartile range, 10%; lower to upper limit, 0%-23%). Among covered nonopioids, prior authorization and step therapy were uncommon, with fewer than 5% affected by prior authorization and 0% by step therapy. However, 13% of covered nonopioids had quantity limits (interquartile range, 10%; lower to upper limit, 0%-31%) and 22% were in high-cost tiers (interquartile range, 38%; lower to upper limit, 0%-50%). Increases in the number of nonopioids excluded on Medicare plans in a county were associated with increased opioid prescribing (effect size relative to mean, 2.2%-3.7%; P = .004). Conversely, increases in the number of opioids not covered on Medicare plans in a county was found to be associated with decreased opioid prescribing (effect size relative to mean, 0.8%-1.5%; P = .02). None of the utilization management strategies (prior authorization, step therapy, and quantity limits) examined or high-cost tier placements of nonopioids were associated with increased opioid prescribing.
Lack of Medicare coverage for pharmacologic alternatives to opioids may be associated with increased opioid prescribing.
尽管有许多阿片类药物的替代药物，但尚不清楚医疗保险 D 部分处方集的结构是否会阻碍替代药物的使用。
量化阿片类药物替代药物的覆盖范围以及这些药物的事先授权、阶梯治疗、数量限制和级别放置的流行程度，并检验这些处方集排除和限制是否与县级老年人群中阿片类药物处方的增加有关。
设计、设置和参与者：使用 2015 年和 2016 年美国 50 个州和哥伦比亚特区的一个县面板，对县固定效应模型进行了估计。数据分析于 2019 年 7 月 1 日至 9 月 23 日进行。样本包括 2015 年的 2721 个县和 2016 年的 2671 个县，这些县的数据足以说明医疗保险 D 部分处方集设计和阿片类药物处方情况。
县级阿片类药物处方率（阿片类药物索赔数除以总索赔数）以及被排除的阿片类药物替代药物和需要事先授权、阶梯治疗、数量限制和高级别放置的阿片类药物替代药物的数量。
在 2015 年的 28997 个医疗保险计划和 2016 年的 30390 个计划中，共检查了 30 种非阿片类镇痛药。医疗保险计划平均未覆盖这些药物的 7%（四分位距，10%；下限至上限，0%-23%）。在被覆盖的非阿片类药物中，事先授权和阶梯治疗并不常见，不到 5%的药物受到事先授权的影响，没有药物受到阶梯治疗的影响。然而，13%的被覆盖的非阿片类药物有数量限制（四分位距，10%；下限至上限，0%-31%），22%属于高成本类别（四分位距，38%；下限至上限，0%-50%）。县内被排除在医疗保险计划之外的非阿片类药物数量的增加与阿片类药物处方的增加有关（相对于平均值的效应大小，2.2%-3.7%；P=0.004）。相反，县内未被医疗保险计划覆盖的阿片类药物数量的增加与阿片类药物处方的减少有关（相对于平均值的效应大小，0.8%-1.5%；P=0.02）。没有任何一种被检查的用药管理策略（事先授权、阶梯治疗和数量限制）或非阿片类药物的高成本类别与阿片类药物处方的增加有关。
缺乏医疗保险对阿片类药物替代药物的覆盖可能与阿片类药物处方的增加有关。
