Spillover effects of state medicaid antipsychotic prior authorization policies in US commercially insured youth

Abstract

Purpose To evaluate spillover effects of Medicaid antipsychotic prior authorization (PA) policies among commercially insured youth. Methods Commercially insured youth residing in nine US states that implemented PA exclusively for antipsychotics in 2011 or 2012 were identified using a 10% random sample of enrollees in the IQVIA PharMetrics Plus database spanning 2007 to 2015. Youth were included if they were ≤18 years, met the age criteria of the PA at the time of dispensing, and had at least 1 month of prescription drug coverage from 2007 to 2015. The primary outcome of interest was the monthly prevalence of antipsychotics. We implemented segmented regression of interrupted time series analysis to estimate changes in the monthly prevalence of targeted medications, overall and stratified by age. Trends were compared in the 4‐year period before and the 3‐year period after implementation of PA policies. Results Antipsychotics prescribing significantly decreased 6.74/10 000 (95% CI, −9.04 to −4.44) enrollees per month immediately after PA implementation. However, PA was not associated with significant long‐term trend changes (−0.06; 95% CI, −0.16 to 0.03). Antipsychotic prescribing in children <12 years‐old significantly decreased 0.14/10 000 (95% CI, −0.21 to −0.07) enrollees per month after PA implementation, while prescribing in adolescents 12 to 18 years‐old significantly increased 0.32/10 000 (95% CI, 0.16 to 0.47) enrollees per month. Conclusion While Medicaid PA polices for antipsychotic oversight did not affect overall prescribing, there were spillover effects in U.S. commercially insured children <12 years‐old. This suggests that state‐level Medicaid policies intended to improve the quality of care and safe use of antipsychotics can have broad reach.

Trends in Antipsychotic Medication Use in Young Privately Insured Children

“…20,21 Although these initiatives are not targeted to privately insured children, many providers treat children across insurance types, and prior authorization programs have been associated with reductions in antipsychotic prescribing in privately insured children. 24 Similarly, in other medical contexts, Medicaid prescribing policies had spillover effects on prescribing practices for privately insured patients. 29,30 In addition, guidance from organizations urging caution prescribing antipsychotics to young children and providing quality measures [11][12][13]31 may have contributed to the declines that we observed.…”

“…6 A recent analysis observed declines in antipsychotic use in privately insured children under age 12 years following the Medicaid antipsychotic prior authorization policies in 9 US states, suggesting spillover effects to privately insured populations. 24 It remains unknown whether trends in antipsychotic prescribing in very young, privately insured children stabilized, declined, or increased through 2017 following declines observed in the early 2010s.…”

Incorporating clinician insight and care plans into an audit and feedback initiative for antipsychotic prescribing to Medicaid-enrolled youth in Philadelphia

“…As a result of these concerns, antipsychotic prescribing has been the target of numerous interventions in the U.S., including the introduction of prior authorization by insurers and the Substance Abuse and Mental Health Service Administration's release of strategies to promote best clinical practices [11][12][13]. These efforts have coincided with a reduction in antipsychotic prescribing in recent years [14][15][16].…”