title: Unintended impacts of a Medicaid prior authorization policy on access to medications for bipolar illness.
abstract: OBJECTIVE
  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.
authors: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
authors: Christine Y
authors: CY
authors: Lu
authors: Stephen B
authors: SB
authors: Soumerai
authors: Dennis
authors: D
authors: Ross-Degnan
authors: Fang
authors: F
authors: Zhang
authors: Alyce S
authors: AS
authors: Adams
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000927:Anticonvulsants / Q000191:economics* / Q000627:therapeutic use; D014150:Antipsychotic Agents / Q000191:economics* / Q000627:therapeutic use; D001714:Bipolar Disorder / Q000188:drug therapy* / Q000191:economics; D003363:Cost Control / Q000191:economics; D003362:Cost-Benefit Analysis; D004334:Drug Administration Schedule; D020793:Gatekeeping / Q000458:organization & administration; D006297:Health Services Accessibility; D006801:Humans; D007345:Insurance Claim Review; D008281:Maine; D008484:Medicaid / Q000191:economics / Q000458:organization & administration*; D008875:Middle Aged; D009513:New Hampshire; D012051:Reimbursement Mechanisms / Q000191:economics / Q000458:organization & administration*; D013997:Time Factors; D014481:United States; D055815:Young Adult
chemical_list: D000927:Anticonvulsants; D014150:Antipsychotic Agents