BOSTON, Mass. (April 1, 2008)--Policies requiring authorization before physicians can prescribe newer medications to schizophrenic patients may be counter-productive. According to a new study, patients in Maine's Medicaid program who found themselves in this situation were 29% more likely to stop or disrupt medication use than patients not subject to the policy. In addition, although the policy was originally designed to cut costs, government savings were minimal at best.
These findings are reported online in Health Affairs.
The study, led by investigators from Harvard Medical School's Department of Ambulatory Care and Prevention, looked at Maine Medicaid beneficiaries with schizophrenia on antipsychotic drugs before, during, and after a policy that required patients to use an authorized medication (step treatment) before they were allowed to use drugs not on the preferred list. They were compared to similar beneficiaries in New Hampshire, where there was no prior authorization regulation. The Maine policy was replaced by a provider education program after less than a year.
Study data indicated that the original Maine policy disrupted essential antipsychotic treatment for vulnerable patients with schizophrenia, with minimal or no cost savings.
"This study calls into question the effectiveness of many similar policies throughout the country," says Stephen Soumerai, Harvard Medical School professor and senior author on the study. "Getting prior authorization requires paperwork and is time-consuming, so physicians may tend to switch to prescribing preferred medications even if they have concerns about the appropriateness of the medication for a specific patient." However, as medication choice is restricted, more patients discontinue treatment.
Previous studies have shown that gaps in antipsychotic medication use are likely to result in recurrence of psychotic episodes and higher hospitalization rates and costs for these patients.
Schizophrenia is a disabling and costly illness that afflicts approximately one percent of the US population, or three million people. Without antipsychotic treatment, about 80% of patients will have a serious recurrence of their illness within a year. The study investigators believe that while there is a legitimate place for prior authorization and step treatment policies for some medications, patients with chronic mental illness are put at particular risk of receiving inadequate treatment.
"Given the tremendous variation in individual responses to these drugs as well as the devastating impact of treatment disruptions on schizophrenic patients, a policy that pushes all patients toward a limited number of preferred drugs may do more harm than good," says Dr. Soumerai. "It would be much better to focus on ensuring that antipsychotic drugs are prescribed for evidence-based reasons and that preferred drugs are prescribed only to patients who can benefit from them."
This study was supported by the Agency for Healthcare Research and Quality (AHRQ), Centers for Education and Research in Therapeutics (CERT) Public/Private Partnership Program and the HMO Research Network CERT, Eli Lilly and Company, and the Harvard Pilgrim Health Care Foundation.
Health Affairs, early online publication, April 1, 2008
"Use of atypical antipsychotic drugs for schizophrenia in Maine Medicaid following a policy change"
Stephen Soumerai(1), Fang Zhang(1), Dennis Ross-Degnan(1), Daniel Erik Ball(2), Robert LeCates(1), Michael Robert Law(1), Tom Hughes(2), Daniel Chapman(3), and Alyce Adams(1)
1-Harvard Medical School, Department of Ambulatory Care and Prevention, Boston MA
2-Eli Lilly and Company, Indianapolis, IN
3-Centers for Disease Control and Prevention, Atlanta GA
Harvard Medical School has more than 7,500 full-time faculty working in 11 academic departments located at the School's Boston campus or in one of 47 hospital-based clinical departments at 17 Harvard-affiliated teaching hospitals and research institutes. Those affiliates include Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Cambridge Health Alliance, Children's Hospital Boston, Dana-Farber Cancer Institute, Forsyth Institute, Harvard Pilgrim Health Care, Joslin Diabetes Center, Judge Baker Children's Center, Immune Disease Institute, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, and VA Boston Healthcare System.