title: Prior authorization for antidepressants in Medicaid: effects among disabled dual enrollees.
abstract: BACKGROUND
  Prior authorization is a popular, but understudied, strategy for reducing medication costs. We evaluated the impact of a controversial prior authorization policy in Michigan Medicaid on antidepressant use and health outcomes among dual Medicaid and Medicare enrollees with a Social Security Disability Insurance designation of permanent disability.
  
  
  METHODS
  We linked Medicaid and Medicare (2000-2003) claims for dual enrollees in Michigan and a comparison state, Indiana. Using interrupted time-series and longitudinal data analysis, we estimated the impact of the policy on antidepressant medication use, treatment initiation, disruptions in therapy, and adverse health events among continuously enrolled (Michigan, n = 28 798; Indiana, n = 21 769) and newly treated (Michigan, n = 3671; Indiana, n = 2400) patients.
  
  
  RESULTS
  In Michigan, the proportion of patients starting nonpreferred agents declined from 53% prepolicy to 20% postpolicy. The prior authorization policy was associated with a small sustained decrease in therapy initiation overall (9 per 10,000 population; P = .007). We also observed a short-term increase in switching among established users of nonpreferred agents overall (risk ratio, 2.88; 95% confidence interval, 1.87-4.42) and among those with depression (2.04; 1.22-3.42). However, we found no evidence of increased disruptions in treatment or adverse events (ie, hospitalization, emergency department use) among newly treated patients.
  
  
  CONCLUSIONS
  Prior authorization was associated with increased use of preferred agents with no evidence of disruptions in therapy or adverse health events among new users. However, unintended effects on treatment initiation and switching among patients already taking the drug were also observed, lending support to the state's previous decision to discontinue prior approval for antidepressants in 2003.
authors.affiliation: Department of Ambulatory Care and Prevention, Harvard Medical School, Harvard Pilgrim Health Care, Boston, Massachusetts, USA. Alyce.S.Adams@kp.org
authors.forename: Alyce S
authors.initials: AS
authors.lastname: Adams
authors.forename: Fang
authors.initials: F
authors.lastname: Zhang
authors.forename: Robert F
authors.initials: RF
authors.lastname: LeCates
authors.forename: Amy Johnson
authors.initials: AJ
authors.lastname: Graves
authors.forename: Dennis
authors.initials: D
authors.lastname: Ross-Degnan
authors.forename: Daniel
authors.initials: D
authors.lastname: Gilden
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: McLaughlin
authors.forename: Christine
authors.initials: C
authors.lastname: Lu
authors.forename: Connie M
authors.initials: CM
authors.lastname: Trinacty
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Soumerai
mesh_terms: D000328:Adult; D000928:Antidepressive Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D003863:Depression / Q000188:drug therapy; D006233:Persons with Disabilities / Q000706:statistics & numerical data*; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D020793:Gatekeeping; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007196:Indiana; D008484:Medicaid / Q000706:statistics & numerical data*; D006278:Medicare / Q000706:statistics & numerical data*; D008824:Michigan; D008875:Middle Aged; D010349:Patient Compliance / Q000706:statistics & numerical data*; D014481:United States; D055815:Young Adult
chemical_list: D000928:Antidepressive Agents