Medicaid prescription drug policies and medication access and continuity: findings from ten states.
TL;DR: It is indicated that more effective Medicaid prescription drug management and financing practices are needed to promote medication continuity and improve treatment outcomes.
Abstract: Objectives: The aims of this study were to compare medication access problems among psychiatric patients in ten state Medicaid programs, assess adverse events associated with medication access problems, and determine whether prescription drug utilization management is associated with access problems and adverse events. Methods: Psychiatrists from the American Medical Association’s Masterfile were randomly selected (N=4,866). Sixty-two percent responded; 32% treated Medicaid patients and were randomly assigned a start day and time to report on two Medicaid patients (N=1,625 patients). Results: A medication access problem in the past year was reported for a mean±SE of 48.3%±2.0% of the patients, with a 37.6% absolute difference between states with the lowest and highest rates (p<.001). The most common access problems were not being able to access clinically indicated medication refills or new prescriptions because Medicaid would not cover or approve them (34.0%±1.9%), prescribing a medication not clinically preferred because clinically indicated or preferred medications were not covered or approved (29.4%±1.8%), and discontinuing medications as a result of prescription drug coverage or management issues (25.8%±1.6%). With patient case mix adjusted to control for sociodemographic and clinical confounders, patients with medication access problems had 3.6 times greater likelihood of adverse events (p<.001), including emergency visits, hospitalizations, homelessness, suicidal ideation or behavior, or incarceration. Also, all prescription drug management features were significantly associated with increased medication access problems and adverse events (p<.001). States with more access problems had significantly higher adverse event rates (p<.001). Conclusions: These associations indicate that more effective Medicaid prescription drug management and financing practices are needed to promote medication continuity and improve treatment outcomes. (Psychiatric Services 60:601– 610, 2009)
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TL;DR: Many dually eligible patients had difficulty accessing psychiatric medications after implementation of Part D and were significantly more likely to visit psychiatric emergency departments than patients who did not experience difficulties, raising concerns about possible negative effects on quality of care.
Abstract: Objective: This study examined the occurrence of medication access problems and use of intensive mental health services after the transition in January 2006 from Medicaid drug coverage to Medicare Part D for persons dually eligible for Medicaid and Medicare benefits. Methods: Psychiatrists randomly selected from the American Medical Association’s Physicians Masterfile reported on experiences of one systematically selected dually eligible patient (N=908) in the nine to 12 months after Part D implementation. Propensity score matching was used to compare use of psychiatric emergency department care and inpatient care between individuals who experienced a problem accessing a psychiatric medication after Part D and those who did not. Results: Approximately 44% of dually eligible patients were reported to have experienced a problem accessing medications. The likelihood of visiting an emergency department was significantly higher for those who experienced an access problem than for those who did not (mean odds ratio=1.75, mean p=.003). There was no difference in number of emergency department visits or hospitalizations for those who had at least one. Conclusions: Many dually eligible patients had difficulty accessing psychiatric medications after implementation of Part D. These patients were significantly more likely to visit psychiatric emergency departments than patients who did not experience difficulties. These findings raise concerns about possible negative effects on quality of care. Additional study is needed to understand the full effects of Part D on outcomes and functioning as well as treatment costs for this population. (Psychiatric Services 60:1169–1174, 2009)
30 citations
TL;DR: Previous BH history, a positive modifier, and foster care predicted postscreening BH services, and although screening is associated with an increase in BH recognition, it may be insufficient to improve care.
Abstract: OBJECTIVES: To determine the relationship of child behavioral health (BH) screening results to receipt of BH services in Massachusetts Medicaid (MassHealth) children. METHODS: After a court decision, Massachusetts primary care providers were mandated to conduct BH screening at well-child visits and use a Current Procedural Terminology code along with a modifier indicating whether a BH need was identified. Using MassHealth claims data, a cohort of continuously enrolled (July 2007-June 2010) children was constructed. The salient visit (first use of the modifier, screening code, or claim in fiscal year 2009) was considered a reference point to examine BH history and postscreening BH services. Bivariate and multivariate logistic regression analyses were performed to determine predictors of postscreening BH services. RESULTS: Of 261 160 children in the cohort, 45% (118 464) were screened and 37% had modifiers. Fifty-seven percent of children screening positive received postscreening BH services compared with 22% of children screening negative. However, only 30% of newly identified children received BH services. The strongest predictors of postscreening BH services for children without a BH history were being in foster care (odds ratio, 10.38; 95% confidence interval, 9.22-11.68) and having a positive modifier (odds ratio, 3.79; 95% confidence interval, 3.53-4.06). CONCLUSIONS: Previous BH history, a positive modifier, and foster care predicted postscreening BH services. Only one-third of newly identified children received services. Thus although screening is associated with an increase in BH recognition, it may be insufficient to improve care. Additional strategies may be needed to enhance engagement in BH services. Language: en
20 citations
TL;DR: Evidence suggests that MTM services are a promising way to manage complex patients, but there are gaps in the literature largely because of the limited number of studies with strong designs.
Abstract: BACKGROUND: Medication therapy management (MTM) is one form of a medication benefit program offered by public and private health providers and insurers. Although the term was first coined in 2003, ...
20 citations
TL;DR: Hospitalization is the authors' most intensive, intrusive, and expensive psychiatric treatment setting, yet in a cohort of formerly hospitalized adolescents fewer than 50% received psychiatry-related aftercare in the month postdischarge, suggesting innovations are necessary to address geographic inequities and improve timely access to mental health aftercare.
Abstract: Objective: Timely aftercare can be viewed as a patient safety imperative. In the context of decreasing inpatient length of stay (LOS) and known child psychiatry human resource challenges, we investigated time to aftercare for adolescents following psychiatric hospitalization. Method: We conducted a population-based cohort study of adolescents aged 15 to 19 years with psychiatric discharge between April 1, 2002, and March 1, 2004, in Ontario, using encrypted identifiers across health administrative databases to determine time to first psychiatric aftercare with a primary care physician (PCP) or a psychiatrist within 395 days of discharge. Results: Among the 7111 adolescents discharged in the study period, 24% had aftercare with a PCP or a psychiatrist within 7 days and 49% within 30 days. High socioeconomic status (adjusted hazard ratio [AHR] 1.31; 95% CI 1.21 to 1.43, P Language: en
19 citations
TL;DR: Modelling the amount of Medicaid expenditures incurred from the purchase of psychotropic drugs for children in the child welfare system found each child with child welfare involvement is likely to incur upwards of $1482 in psychotropic medication expenditures throughout his or her enrollment in Medicaid.
Abstract: Objective: Children in the child welfare system are the most expensive child population to insure for their mental health needs. The objective of this article is to estimate the amount of Medicaid expenditures incurred from the purchase of psychotropic drugs – the primary drivers of mental health expenditures – for these children. Methods: We linked a subsample of children interviewed in the first nationally representative survey of children coming into contact with U.S. child welfare agencies, the National Survey of Child and Adolescent Well-Being (NSCAW), to their Medicaid claims files obtained from the Medicaid Analytic Extract. Our data consist of children living in 14 states, and Medicaid claims for 4 years, adjusted to 2010 dollars. We compared expenditures on psychotropic medications in the NSCAW sample to a propensity score-matched comparison sample obtained from Medicaid files. Results: Children surveyed in NSCAW had over thrice the odds of any psychotropic drug use than the comparison s...
18 citations
References
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TL;DR: Strategies to assess and enhance medication adherence (or compliance) are reviewed, to help patients adhere to prescribed treatment regimens and avoid stigmatization.
Abstract: The full benefit of many effective medications will be achieved only if patients adhere to prescribed treatment regimens. Unfortunately, applying terms such as “noncompliant” and “nonadherent” to patients who do not consume every pill at the desired time can stigmatize them in their future relationships with health care providers. This article on medication adherence (or compliance) reviews strategies to assess and enhance this important aspect of patient care.
7,204 citations
TL;DR: Olanzapine was the most effective in terms of the rates of discontinuation, and the efficacy of the conventional antipsychotic agent perphenazine appeared similar to that of quetiapine, risperidone, and ziprasidone.
Abstract: background The relative effectiveness of second-generation (atypical) antipsychotic drugs as compared with that of older agents has been incompletely addressed, though newer agents are currently used far more commonly. We compared a first-generation antipsychotic, perphenazine, with several newer drugs in a double-blind study. methods A total of 1493 patients with schizophrenia were recruited at 57 U.S. sites and randomly assigned to receive olanzapine (7.5 to 30 mg per day), perphenazine (8 to 32 mg per day), quetiapine (200 to 800 mg per day), or risperidone (1.5 to 6.0 mg per day) for up to 18 months. Ziprasidone (40 to 160 mg per day) was included after its approval by the Food and Drug Administration. The primary aim was to delineate differences in the overall effectiveness of these five treatments. results Overall, 74 percent of patients discontinued the study medication before 18 months (1061 of the 1432 patients who received at least one dose): 64 percent of those assigned to olanzapine, 75 percent of those assigned to perphenazine, 82 percent of those assigned to quetiapine, 74 percent of those assigned to risperidone, and 79 percent of those assigned to ziprasidone. The time to the discontinuation of treatment for any cause was significantly longer in the olanzapine group than in the quetiapine (P<0.001) or risperidone (P=0.002) group, but not in the perphenazine (P=0.021) or ziprasidone (P=0.028) group. The times to discontinuation because of intolerable side effects were similar among the groups, but the rates differed (P=0.04); olanzapine was associated with more discontinuation for weight gain or metabolic effects, and perphenazine was associated with more discontinuation for extrapyramidal effects. conclusions The majority of patients in each group discontinued their assigned treatment owing to inefficacy or intolerable side effects or for other reasons. Olanzapine was the most effective in terms of the rates of discontinuation, and the efficacy of the conventional antipsychotic agent perphenazine appeared similar to that of quetiapine, risperidone, and ziprasidone. Olanzapine was associated with greater weight gain and increases in measures of glucose and lipid metabolism.
5,437 citations
TL;DR: The acute and longer-term treatment outcomes associated with each of four successive steps in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial are described and compared.
Abstract: Objective: This report describes the participants and compares the acute and longer-term treatment outcomes associated with each of four successive steps in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. Method: A broadly representative adult outpatient sample with nonpsychotic major depressive disorder received one (N=3,671) to four (N=123) successive acute treatment steps. Those not achieving remission with or unable to tolerate a treatment step were encouraged to move to the next step. Those with an acceptable benefit, preferably symptom remission, from any particular step could enter a 12-month naturalistic follow-up phase. A score of ≤5 on the Quick Inventory of Depressive Symptomatology–Self-Report (QIDS-SR 16 ) (equivalent to ≤7 on the 17-item Hamilton Rating Scale for Depression [HRSD 17 ]) defined remission; a QIDS-SR 16 total score of ≥11 (HRSD 17 ≥14) defined relapse. Results: The QIDS-SR 16 remission rates were 36.8%, 30.6%, 13.7%, and 13.0% for the first, second, t...
3,768 citations
TL;DR: There is a high rate of relapse within 5 years of recovery from a first episode of schizophrenia and schizoaffective disorder, and this risk is diminished by maintenance antipsychotic drug treatment.
Abstract: Background We examined relapse after response to a first episode of schizophrenia or schizoaffective disorder. Methods Patients with first-episode schizophrenia were assessed on measures of psychopathologic variables, cognition, social functioning, and biological variables and treated according to a standardized algorithm. The sample for the relapse analyses consisted of 104 patients who responded to treatment of their index episode and were at risk for relapse. Results Five years after initial recovery, the cumulative first relapse rate was 81.9% (95% confidence interval [CI], 70.6%-93.2%); the second relapse rate was 78.0% (95% CI, 46.5%-100.0%). By 4 years after recovery from a second relapse, the cumulative third relapse rate was 86.2% (95% CI, 61.5%-100.0%). Discontinuing antipsychotic drug therapy increased the risk of relapse by almost 5 times (hazard ratio for an initial relapse, 4.89 [99% CI, 2.49-9.60]; hazard ratio for a second relapse, 4.57 [99% CI, 1.49-14.02]). Subsequent analyses controlling for antipsychotic drug use showed that patients with poor premorbid adaptation to school and premorbid social withdrawal relapsed earlier. Sex, diagnosis, obstetric complications, duration of psychotic illness before treatment, baseline symptoms, neuroendocrine measures, methylphenidate hydrochloride challenge response, neuropsychologic and magnetic resonance imaging measures, time to response of the initial episode, adverse effects during treatment, and presence of residual symptoms after the initial episode were not significantly related to time to relapse. Conclusions There is a high rate of relapse within 5 years of recovery from a first episode of schizophrenia and schizoaffective disorder. This risk is diminished by maintenance antipsychotic drug treatment.
1,189 citations
TL;DR: Increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions.
Abstract: ContextRising costs of medications and inequities in access have sparked calls
for drug policy reform in the United States and Canada. Control of drug expenditures
by prescription cost-sharing for elderly persons and poor persons is a contentious
issue because little is known about the health impact in these subgroups.ObjectivesTo determine (1) the impact of introducing prescription drug cost-sharing
on use of essential and less essential drugs among elderly persons and welfare
recipients and (2) rates of emergency department (ED) visits and serious adverse
events associated with reductions in drug use before and after policy implementation.Design and SettingInterrupted time-series analysis of data from 32 months before and 17
months after introduction of a prescription coinsurance and deductible cost-sharing
policy in Quebec in 1996. Separate 10-month prepolicy control and postpolicy
cohort studies were conducted to estimate the impact of the drug reform on
adverse events.ParticipantsA random sample of 93 950 elderly persons and 55 333 adult
welfare medication recipients.Main Outcome MeasuresMean daily number of essential and less essential drugs used per month,
ED visits, and serious adverse events (hospitalization, nursing home admission,
and mortality) before and after policy introduction.ResultsAfter cost-sharing was introduced, use of essential drugs decreased
by 9.12% (95% confidence interval [CI], 8.7%-9.6%) in elderly persons and
by 14.42% (95% CI, 13.3%-15.6%) in welfare recipients; use of less essential
drugs decreased by 15.14% (95% CI, 14.4%-15.9%) and 22.39% (95% CI, 20.9%-23.9%),
respectively. The rate (per 10 000 person-months) of serious adverse
events associated with reductions in use of essential drugs increased from
5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly
persons (a net increase of 6.8 [95% CI, 5.6-8.0]) and from 14.7 to 27.6 in
welfare recipients (a net increase of 12.9 [95% CI, 10.2-15.5]). Emergency
department visit rates related to reductions in the use of essential drugs
also increased by 14.2 (95% CI, 8.5-19.9) per 10 000 person-months in
elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1)
and by 54.2 (95% CI, 33.5-74.8) among welfare recipients (prepolicy control
cohort, 69.6; postpolicy cohort, 123.8). These increases were primarily due
to an increase in the proportion of recipients who reduced their use of essential
drugs. Reductions in the use of less essential drugs were not associated with
an increase in risk of adverse events or ED visits.ConclusionsIn our study, increased cost-sharing for prescription drugs in elderly
persons and welfare recipients was followed by reductions in use of essential
drugs and a higher rate of serious adverse events and ED visits associated
with these reductions.
893 citations