Modifying prescribing behaviour of angiotensin receptor blockers by selectively rescinding managerial prior authorization requirements for losartan

Abstract

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT• The utility of a prior authorization (PA) requirement for curtailing the prescription of expensive drugs and improving quality of care has been well substantiated. Although studies have evaluated changes in prescribing behaviour after revocation of a PA requirement, the effectiveness of selective revocation for the first drug within a class to go off patent as an incentive to reduce prescription of the more expensive drugs has not been studied.WHAT THIS STUDY ADDS• Rescinding the PA requirement for a generic drug alone within a pharmacological category upon its introduction into the market is a successful managerial strategy for reduction of prescription of the more expensive drugs still on patent in that class. The observed duration of effect was approximately 1 year.AIMS To evaluate whether rescinding the prior authorization (PA) requirement (managerial pre‐approval) for losartan in an health maintenance organization (HMO) could reduce prescribing of the more expensive angiotensin receptor blockers (ARBs).METHODS HMO physicians were notified that losartan would no longer require PA, and appropriate changes were made to the electronic prescribing computer program. The monthly distribution by drug of the number of prescriptions for ARBs dispensed for new patients was calculated before and after the policy change from data captured from electronic records. The proportion of patients (percentage and 95% confidence interval) treated with losartan who met the criteria for treatment with ARBs (hypertension or cardiac insufficiency in patients who have developed adverse effects in response to angiotensin‐converting enzyme inhibitors or macroproteinuria) during the first month after the PA requirement was rescinded was calculated.RESULTS The total number of PA requests for ARBs declined by 48.6% from 961 in December 2008, the month before the policy change, to 494 the following January, rising again to 651 during January 2010. Prescription incidence changed from 121 to 255 patients treated per month (114% increase) for losartan, from 15 to 16 (6.7% increase) for candesartan, and from 89 to 71 (20.2% decrease) for valsartan. The duration of effect for decrease in ARB requests for the more expensive drugs was approximately 1 year. Only 23.3% (95% confidence interval 18.1–28.4) of patients receiving losartan met the criteria for receiving ARBs.CONCLUSIONS Rescinding the PA requirement for this drug alone was an effective limited‐duration strategy for reduction of prescription of relatively expensive drugs.

Retrospective Database Analysis of the Impact of Prior Authorization for Type 2 Diabetes Medications on Health Care Costs in a Medicare Advantage Prescription Drug Plan Population

“…Kahan et al (2011) evaluated whether rescinding the PA policy for losartan in a health maintenance organization (HMO) could reduce prescribing of more expensive angiotensin receptor blockers. 15 The authors found that doing so was an "effective limited-duration strategy for the reduction of prescription of relatively expensive drugs." Therefore, PA policies do have an impact on prescribing behavior, particularly in an HMO environment.…”

Practice characteristics and prior authorization costs: secondary analysis of data collected by SALT-Net in 9 central New York primary care practices

“…Thus, these findings complement the estimates from previous studies by providing the granularity that is needed to inform both the practice and legislative communities about the burden of prior authorization activities on primary care practices [ 19 ]. It is also important to consider that prior authorization requirements may yield benefits, such as cost savings to the system [ 20 ] or the promotion of rational prescribing trends [ 21 ], although to date, the literature on this point appears to be equivocal [ 2 , 22 - 27 ]. In light of the pivotal role of primary care now and in the future [ 28 - 30 ], the benefits and costs of prior authorization activities in primary care deserves further understanding and action, and primary care offices should be appropriately compensated for this work.…”

Two cheers or three for treatment guidelines? Nudging prescribers in right directions

“…Kahan and colleagues demonstrated that within a health insurance network, the simple act of removing the need for prior authorization for losartan prescriptions had the desired effect of achieving a marked drop in prescriptions for valsartan and a switch towards the less expensive preparations of losartan [8]: modifying the behaviour of physicians may be less to do with erudite guidance and exhortations, but more to do with providing the relevant (dis)incentives via a route of least 'hassle' .…”