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Unintended Impacts of a Medicaid Prior Authorization Policy on Access to Medications for Bipolar Illness

Lu, Christine Y. PhD*†; Soumerai, Stephen B. ScD*; Ross-Degnan, Dennis ScD*; Zhang, Fang PhD*; Adams, Alyce S. PhD*‡

doi: 10.1097/MLR.0b013e3181bd4c10
Original Article

Objectives: 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.

Methods: 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.

Results: 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).

Conclusions: 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.

From the *Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA; †School of Pharmacy and Medical Sciences, Sansom Institute, University of South Australia, Adelaide, Australia; and ‡Division of Research, Kaiser Permanente, Oakland, CA.

Supported by the Robert Wood Johnson Foundation's Changes in Health Care Financing and Organization Program, “Effects of Prior Authorization on New Medications among Medicare Beneficiaries with Bipolar Disorder” (grant No. 63213, to S.B.S.). Methods for this study were based on a previous study supported by the National Institute for Mental Health (NIMH, grant 5R01MH069776-03) conducted by the research team. Also, supported by a Fellowship in Pharmaceutical Policy at Harvard Medical School and a Sir Keith Murdoch Fellowship by the American Australian Association (to C.Y.L.) and by the Kaiser Permanente Northern California Community Benefit Program (to A.S.A.).

F.Z. and S.B.S. are investigators in the HMO Research Network Center for Education and Research in Therapeutics and are supported by the Agency for Healthcare Research and Quality.

This work was conducted at the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute.

Reprints: Prof S.B. Soumerai, ScD, 133 Brookline Avenue, 6th Floor, Boston, MA 02215 USA. E-mail: ssoumerai@hms.harvard.edu.

© 2010 Lippincott Williams & Wilkins, Inc.