Prior authorization of atypicals cuts all antipsychotic use

March 15, 2012

Requiring prior authorization may have a broader impact than expected.

"If the reduction in the use of atypicals leads through decline in overall antipsychotic use to more poorly controlled schizophrenia in already vulnerable populations, this potentially could have quite severe cost implications," said senior author Dana Goldman, MD, professor of medicine and public policy at the University of Southern California, Los Angeles.

"However, if most of the reductions in antipsychotic use were shown to be reductions in inappropriate use, then using prior authorization could produce benefits to patients in addition to cost savings for Medicaid," Goldman said.

The article, "Medicaid cost control measures aimed at second-generation antipsychotics led to less use of all antipsychotics," was published in the December 2011 issue of Health Affairs. The study was funded by the National Institutes of Health and Janssen Pharmaceuticals.

Researchers reviewed Medicaid policy and fee-for-service claims for antipsychotic, antidepressant, and anticonvulsant agents between 1999 and 2008. They found that prior authorization and other restrictions on atypical agents resulted in a 3.1% decline in the use of all antipsychotic agents. Restricting use of the 2 most often-prescribed atypicals reduced total antipsychotic use by 5.9%. It is not clear why restricting the use of atypicals reduces the use of all antipsychotics, including conventional agents.

Antipsychotics have traditionally been exempted from Medicaid utilization restrictions, but attitudes are changing. One reason is that psychotherapeutic drugs account for one-quarter of all Medicaid drug spending.

"Fiscal pressures have caused a reexamination of this position in many states due to atypical antipsychotic expense increasing significantly since 2000," said Jerry McKee, PharmD, MS, BCPP, associate director of behavioral health pharmacy programs, Community Care of North Carolina, Raleigh, N.C. "This study demonstrates that psychiatric and neurologic medications are no longer viewed as 'untouchable' from the perspective of state Medicaid agencies."

Researchers compared prescribing restrictions and spending in 30 state Medicaid programs. The states were selected based on the availability of fee-for-service claims data and included states with and without prior authorization requirements.

Across all 30 states, spending on antipsychotic agents increased by 106%, from $82 per enrollee in 1999 to $169 per enrollee in 2005. The number of antipsychotic prescriptions grew by 29% over the same period, from 0.54 per enrollee to 0.70.

States that instituted restrictions on atypicals showed lower growth in spending. In the 11 states that restricted atypicals, use per enrollee grew by 14%. In states that did not restrict atypicals, use per enrollee grew by 19% over the study period.

But for unknown reasons, restrictions on atypicals did not produce a corresponding increase in the use of conventional antipsychotic agents, which were not restricted. And states with more strict restrictions on atypicals showed a more rapid drop in the use of all antipsychotics. Using deidentified claims data, it was impossible to tell if the overall drop in atypical use was due to a decline in inappropriate prescribing or an increase in the number of patients who did not receive any treatment because of the restrictions.

"We understand that there is not enough money in Medicaid to go around," McKee said. "But restrictions can tie prescribers' hands. If the patient has to go back to the prescriber, treatment becomes problematic because of the condition itself as well as transportation and other problems."

Electronic prescribing could help reduce the spillover from restrictions on atypical use. Most e-prescribing systems include a drug-formulary lookup to identify potential restrictions and solutions at the point of prescribing.

"There is general awareness of the need to improve the prior authorization process," said Marcie Bough, PharmD, senior director, government affairs, American Pharmacists Association. "Electronic prescribing can help streamline the process."