Robert F. LeCates

Access to care and medicines, burden of health care expenditures, and risk protection: Results from the World Health Survey

OBJECTIVES We assessed the contribution of health insurance and a functioning public sector to access to care and medicines and household economic burden. METHODS We used descriptive and logistic regression analyses on 2002/3 World Health Survey data in 70 countries. RESULTS Across countries, 286,803 households and 276,362 respondents contributed data. More than 90% of households had access to acute care. However, less than half of respondents with a chronic condition reported access. In 51 low and middle income countries (LMIC), health care expenditures accounted for 13-32% of total 4-week household expenditures. One in four poor households in low income countries incurred potentially catastrophic health care expenses and more than 40% used savings, borrowed money, or sold assets to pay for care. Between 41% and 56% of households in LMIC spent 100% of health care expenditures on medicines. Health insurance and a functioning public sector were both associated with better access to care and lower risk of economic burden. CONCLUSION To improve access, policy makers should improve public sector provision of care, increase health insurance coverage, and expand medicines benefit policies in health insurance systems.

Use Of Atypical Antipsychotic Drugs For Schizophrenia In Maine Medicaid Following A Policy Change

More than one-third of Medicaid programs and Medicare Part D plans use prior authorization (PA) policies to control the use of atypical antipsychotics (AAs). We used Medicaid and Medicare claims data to investigate how Maines PA policy affected AA use, treatment discontinuities, and spending among schizophrenia patients initiating AA therapy. Patients initiating AAs during Maines policy experienced a 29 percent greater risk of treatment discontinuity than patients initiating AAs before the policy took effect; no change occurred in a comparison state. AA spending was slightly lower in both states. Observed increases in treatment discontinuities without cost savings suggest that AAs should be exempt from PA for patients with severe mental illnesses.

Chronic acid-related disorders are common and underinvestigated

OBJECTIVES:The aims of this study were as follows: to establish the prevalence of chronic acid-related disorders in a managed care population; to describe these patients; and to examine rates of adherence to current guidelines for investigation of dyspepsia and peptic ulcer disease.METHODS:The design was a population-based cohort study. The sample was drawn from 216,720 adult (aged >18 yr) members of a managed care organization that had an electronic medical record linked to administrative and pharmacy databases. We included adults with continuous enrollment from July, 1998, to January, 2000, who were dispensed histamine-2 blockers or proton-pump inhibitors, or both, for ≥1 yr. Dispensing data, sociodemographic and clinical information, comorbidities, and investigations were collected and analyzed.RESULTS:The final cohort consisted of 5064 patients; 64% were aged ≥50 yr, 47% were male, and 11% were African American. The prevalence of chronic acid-related disorders was 2.3%. Gastroesophageal reflux disease (59%) was the most common condition, followed by dyspepsia (35% of cohort; 18% investigated by endoscopy). There were 917 dyspepsia patients ≥50 yr who had not been investigated by endoscopy (81% of dyspepsia patients in this age group). There were 97 patients with peptic ulcer disease who did not have a documented test for Helicobacter pylori (34% of patients with peptic ulcer disease).CONCLUSIONS:Chronic acid-related disorders are common in primary care, and many patients use acid suppressing medications on a long-term basis. Nevertheless, according to current practice guidelines, our patients were underinvestigated. Future guidelines should specifically address the management of patients who use acid suppressing medications on a chronic basis.

Prior Authorization for Antidepressants in Medicaid : Effects Among Disabled Dual Enrollees

BACKGROUND Prior authorization is a popular, but understudied, strategy for reducing medication costs. We evaluated the impact of a controversial prior authorization policy in Michigan Medicaid on antidepressant use and health outcomes among dual Medicaid and Medicare enrollees with a Social Security Disability Insurance designation of permanent disability. METHODS We linked Medicaid and Medicare (2000-2003) claims for dual enrollees in Michigan and a comparison state, Indiana. Using interrupted time-series and longitudinal data analysis, we estimated the impact of the policy on antidepressant medication use, treatment initiation, disruptions in therapy, and adverse health events among continuously enrolled (Michigan, n = 28 798; Indiana, n = 21 769) and newly treated (Michigan, n = 3671; Indiana, n = 2400) patients. RESULTS In Michigan, the proportion of patients starting nonpreferred agents declined from 53% prepolicy to 20% postpolicy. The prior authorization policy was associated with a small sustained decrease in therapy initiation overall (9 per 10,000 population; P = .007). We also observed a short-term increase in switching among established users of nonpreferred agents overall (risk ratio, 2.88; 95% confidence interval, 1.87-4.42) and among those with depression (2.04; 1.22-3.42). However, we found no evidence of increased disruptions in treatment or adverse events (ie, hospitalization, emergency department use) among newly treated patients. CONCLUSIONS Prior authorization was associated with increased use of preferred agents with no evidence of disruptions in therapy or adverse health events among new users. However, unintended effects on treatment initiation and switching among patients already taking the drug were also observed, lending support to the states previous decision to discontinue prior approval for antidepressants in 2003.

Predictors of antibiotic use in African communities: evidence from medicines household surveys in five countries.

Objectives  To investigate antibiotic use in five national household surveys conducted with the WHO methodology to identify key determinants of antibiotic use in the community.

Impact of Two Medicaid Prior-Authorization Policies on Antihypertensive Use and Costs Among Michigan and Indiana Residents Dually Enrolled in Medicaid and Medicare: Results of a Longitudinal, Population-Based Study

BACKGROUND In response to rising pharmaceutical costs, many state Medicaid programs have implemented policies requiring prior authorization for high-cost medications, even for established users. However, little is known about the impact of these policies on the use of antihypertensive medicines in the United States. OBJECTIVE The aim of this longitudinal, population-based study was to assess comprehensive prior-authorization programs for antihypertensives on drug use and costs in a vulnerable Medicaid population in Michigan and Indiana. METHODS A prior-authorization policy for antihypertensives was implemented in Michigan in March 2002 and in Indiana in September 2002; Indiana also implemented an antihypertensive stepwise-therapy requirement in July 2003. Our study cohort included individuals aged >or=18 years in Michigan and Indiana who were continuously enrolled in both Medicaid and Medicare from July 2000 through September 2003. Claims data were obtained from the Centers for Medicare and Medicaid Services. We included all antihypertensive medications, including diuretics, angiotensin-converting enzyme inhibitors, calcium channel blockers, beta-blockers, alpha-blockers, and angiotcnsin II receptor blockers. We used interrupted time-series analysis to study policy-related changes in the total number and cost of antihypertensive prescriptions. RESULTS Overall, 38,684 enrollees in Michigan and 29,463 in Indiana met our inclusion criteria. Slightly more than half of our cohort in both states was female (53.29%in Michigan and 56.32%in Indiana). In Michigan, 20.23% of patients were aged >or=65 years; 77.44% were white, 20.11% were black, and the remainder were Hispanic, Native American, Asian, or of other or unknown race. In Indiana, 20.07% were aged >or=65 years; 84.93% were white, 13.64% were black, and the remainder were Hispanic, Native American, Asian, or of other or unknown race. The implementation of both policies was associated with large and immediate reductions in the use of nonpreferred medications: 83.33% reduction in the use of such drugs in Michigan (-84.30 prescriptions per 1000 enrollees per month; P < 0.001) and 35.76% in Indiana (-64.45 prescriptions per 1000 enrollees per month; P < 0.001). As expected, use of preferred medications also increased substantially in both states (P < 0.001). Overall, antihypertensive therapy immediately dropped 0.16% in Michigan (P = 0.04) and 1.82% in Indiana (P = 0.02). Implementation of the policies was also associated with reductions in pharmacy reimbursement of

Impact of prior authorization on the use and costs of lipid-lowering medications among Michigan and Indiana dual enrollees in Medicaid and Medicare: results of a longitudinal, population-based study.

616,572.43 in Michigan and

Colorectal Cancer Screening in a Nationwide High-deductible Health Plan Before and After the Affordable Care Act.

868,265.97 in Indiana in the first postpolicy year. CONCLUSIONS Prior authorization was associated with lower use of nonpreferred antihypertensive drugs that was largely offset by increases in the use of preferred drugs. The possible clinical consequences of policy-induced drug switching for individual patients remain unknown because the present study did not include access to medical record data. Further research is needed to establish whether large-scale switches in medicines following the inception of prior-authorization policies have any long-term health effects.

Variation in Postpartum Glycemic Screening in Women With a History of Gestational Diabetes Mellitus.

BACKGROUND Some Medicaid programs have adopted prior-authorization (PA) policies that require prescribers to request approval from Medicaid before prescribing drugs not included on a preferred drug list. OBJECTIVE This study examined the association between PA policies for lipid-lowering agents in Michigan and Indiana and the use and cost of this drug class among dual enrollees in Medicare and Medicaid. METHODS Michigan and Indiana claims data from the Centers for Medicare and Medicaid Services were assessed. Michigan Medicaid instituted a PA requirement for several lipid-lowering medications in March 2002; Indiana implemented a PA policy for drugs in this class in September 2002. Although the PA policies affected some statins, they predominantly targeted second-line treatments, including bile acid sequestrants, fibrates, and niacins. Individuals aged ≥18 years who were continuously dually enrolled in both Medicare and Medicaid from July 2000 through September 2003 were included in this longitudinal, population-based study, which included a 20-month observation period before the implementation of PA in Michigan and a 12-month follow-up period after the Indiana PA policy was initiated. Interrupted time series analysis was used to examine changes in prescription rates and pharmacy costs for lipid-lowering drugs before and after policy implementation. RESULTS A total of 38,684 dual enrollees in Michigan and 29,463 in Indiana were included. Slightly more than half of the cohort were female (Michigan, 53.3% [20,614/38,684]; Indiana, 56.3% [16,595/29,463]); nearly half were aged 45 to 64 years (Michigan, 43.7% [16,921/38,684]; Indiana, 45.2% [13,321/29,463]). Most subjects were white (Michigan, 77.4% [29,957/38,684]; Indiana: 84.9% [25,022/29,463]). The PA policy was associated with an immediate 58% reduction in prescriptions for nonpreferred medications in Michigan and a corresponding increase in prescriptions for preferred agents. However, the PA policy had no apparent effect in Indiana, where there had been little use of nonpreferred medications before the policy was implemented (3.3%). The policies were associated with an immediate reduction of

Controlled trial of interventions to increase testing and treatment for Helicobacter pylori and reduce medication use in patients with chronic acid‐related symptoms

24,548 in prescription expenditures in Michigan and an immediate reduction of