Clinical Prior Authorization Edit Curbs Costs for ADD/ADHD Population in Fee-For-Service Arrangements
San Diego—A new study examining the impact of a recently implemented clinical prior authorization edit for attention deficit disorder (ADD) and attention deficit/hyperactivity disorder (ADHD) found that the edit costs increased at a significantly lower rate for Medicaid patients in fee-for-service (FFS) plans but had less of an impact on Medicaid patients in managed care organizations (MCOs). The findings from the study were presented at the AMCP meeting during a poster session titled Impact Analysis of an Implemented ADD/ADHD Clinical Edit in a Medicaid Population.
ADD/ADHD is a prevalent neuropsychiatric disorder affecting children in the United States. According to data from the Centers for Disease Control and Prevention, in 2011, it had been diagnosed in 11% of children age 4 to 17 in the United States, up from 7.8% in 2003. But ADD/ADHD is not a concern that usually ends at childhood, 4.4% of adults age 18 to 44 have also been said to have the disorder.
To treat ADD/ADHD, many patients are using medication-based therapy; however, these medications also come with significant costs. According to the study, 1 option payers are using to control these costs is implementing clinical prior authorizations.
To determine just how effective this strategy is, researchers studied the impact of a newly implemented clinical authorization edit to improve utilization of extended-release stimulants, immediate-release stimulants, and nonstimulants in 2 Medicaid popu- lation groups: those in FFS plans and those in MCO arrangements.
The retrospective analysis was done using pharmacy and medical claims data. Patients were included in the statistical analysis if they had at least 1 claim for a targeted ADD/ADHD medication before the clinical edit was implemented in February 2014 and another after it was in place.
The clinical edit addressed aspects such as an age limit for specific medications, a history of substance abuse with stimulants, quantity limits, and FDA indicated diagnoses for patients ≥19 years of age. The primary end point of the study was the impact of the clinical prior authorization edit on utilization and reimbursement for Medicaid patients.
Investigators found that costs rose in both groups after the implementation of the clinical prior authorization edit; however, the increase was significantly less for those in the FFS group. According to the study’s findings, the per-member-per-month cost for the FFS group went from $151.57 before the prior authorization edit was implemented to $161.60 after it had been implemented, or a total increase of $10.03. The MCO group, however, saw an increase from $106.82 before implementation to $121.53 after implementation, or an increase of $14.70.
The use of the prior authorization edit seemed to impact certain subgroups more than others, with some FFS clinical feature groups seeing a reduction in utilization and costs of ADD/ADHD as high as 79.5%. According to the study, the 2 clinical features that seemed to have the greatest impact on utilization after implementation were history of substance abuse and age.
The investigators concluded that 1 of the factors contributing to the cost differences seen between FFS and MCO groups could be clinical prior authorization and the different tools being used to accomplish these authorizations.
They also acknowledged several study limitations including that the pharmacy and medical claims data from the MCOs might be incomplete, members may have transitioned between the 2 types of plans, the edit implementation by the MCOs was voluntary, and investigators only assessed utilization changes within single clinical features of an edit.—Jill Sederstrom
This study was supported by Health Information Systems.
