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Journal ArticleDOI

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: Paliperidone does not associate with lower total costs compared with commonly used SGAs, whereas lurasidone is associated with lowerTotal health costs, and high access fees of lurasIDone are not necessarily a major concern in prescription.
Abstract: BACKGROUND: Oral paliperidone and lurasidone are new second-generation antipsychotics (SGAs). Empirical evidence on the comparative costs and persistence of these 2 agents are absent in the literat...

5 citations

Journal ArticleDOI
TL;DR: A public-academic partnership in New Hampshire and a quality improvement program it carried out encourages providers at community mental health centers to adopt prescribing practices that limit the cardiometabolic side effects of antipsychotic medicines.
Abstract: State mental health authorities can use public-academic partnerships to create professional roles in which leaders can track trends, identify problems, and carry out quality improvement projects to address key issues. Leaders with positions in both academic institutions and state mental health authorities ensure access to resources, technical expertise, and key relationships to improve quality. The authors describe a public-academic partnership in New Hampshire and a quality improvement program it carried out. The program encourages providers at community mental health centers to adopt prescribing practices that limit the cardiometabolic side effects of antipsychotic medicines. (Psychiatric Services 62:1004–1006, 2011)

3 citations

01 Jan 2014
TL;DR: This research found generic substitution policy as an efficient way in cost containment in Michigan Medicaid prescription drugs program.
Abstract: High health care costs have left millions of people unable to buy health insurance and has broadened the state’s responsibility to protect low-income families through Medicaid programs. Increasing health care costs have created severe toll on fiscal management of federal and state governments. Prescription drugs are a significant part of Michigan’s Medicaid costs. Due to the economic recession and the downsizing of auto sector the number of Medicaid beneficiaries in Michigan has increased over the years. Thus it has increased Medicaid prescription drugs program costs at a fast pace, which creates fiscal burden on Michigan in administering the program and providing prescription drugs for its beneficiaries. Michigan has implemented several strategies for cost containment of Medicaid since 2001. These strategies have brought modest results in terms of cost containment in Medicaid prescription drugs program. This study examined whether a generic substitution policy of Medicaid prescription drugs in Michigan would be an efficient and effective cost-containment strategy. In doing so, it emphasizes three questions: First, will a generic substitution policy be an efficient strategy in containing Medicaid prescription drug program costs for Michigan? Second, if not in general, are there any “heavily used” brand drugs for which generic substitutes are available that can Michigan safely reduce Medicaid costs by implementing a higher use of generic substitution, thus saving the state in prescription drug costs through the generic substitution policy? Third, if the answer is yes for the two previous questions, then approximately how much money can Michigan save per year by implementing the generic substitution policy? This research found generic substitution policy as an efficient way in cost containment in Michigan Medicaid prescription drugs program.

3 citations

Journal ArticleDOI
TL;DR: In this article, the effects of pharmacy benefit design programs, including a change in PBM, institution of a prescription out-of-pocket maximum, and a mandated switch to 90 days medication supply, on adherence to chronic disease medications over time were assessed.
Abstract: Pharmacy benefit design is one tool for improving access and adherence to medications for the management of chronic disease. We assessed the effects of pharmacy benefit design programs, including a change in pharmacy benefit manager (PBM), institution of a prescription out-of-pocket maximum, and a mandated switch to 90 days’ medication supply, on adherence to chronic disease medications over time. We used a difference-in-differences design to assess changes in adherence to chronic disease medications after the transition to new prescription policies. We utilized claims data from adults aged 18–64, on ≥ 1 medication for chronic disease, whose insurer instituted the prescription policies (intervention group) and a propensity score–matched comparison group from the same region. The outcome of interest was adherence to chronic disease medications measured by proportion of days covered (PDC) using pharmacy claims. There were 13,798 individuals in each group after propensity score matching. Compared to the matched control group, adherence in the intervention group decreased in the first quarter of 2015 and then increased back to pre-intervention trends. Specifically, the change in adherence compared to the last quarter of 2014 in the intervention group versus controls was − 3.6 percentage points (pp) in 2015 Q1 (p < 0.001), 0.65 pp in Q2 (p = 0.024), 1.1 pp in Q3 (p < 0.001), and 1.4 pp in Q4 (p < 0.001). In this cohort of commercially insured adults on medications for chronic disease, a change in PBM accompanied by a prescription out-of-pocket maximum and change to 90 days’ supply was associated with short-term disruptions in adherence followed by return to pre-intervention trends. A small improvement in adherence over the year of follow-up may not be clinically significant. These findings have important implications for employers, insurers, or health systems wishing to utilize pharmacy benefit design to improve management of chronic disease.

2 citations

01 Jan 2010
TL;DR: This paper examined the controversy surrounding a large real-world trial of schizophrenia treatments and concluded that the initial presentation of results led to overly simplistic policy suggestions that had the potential to harm patients.
Abstract: Comparative effectiveness research holds great promise for improving the care of people with mental health conditions and disorders related to substance abuse. But inappropriate application of such research can threaten the quality of that care. We examine the controversy surrounding a large real-world trial of schizophrenia treatments and conclude that the initial presentation of results led to overly simplistic policy suggestions that had the potential to harm patients. Patient advocacy groups helped illuminate these consequences and helped stimulate further discussion and analysis. Researchers must engage stakeholders, especially patients, in all aspects of comparative effectiveness research and translate the findings into sound mental health policy and practice.

1 citations

References
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Journal ArticleDOI
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

Journal ArticleDOI
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

Journal ArticleDOI
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

Journal ArticleDOI
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

Journal ArticleDOI
24 Jan 2001-JAMA
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