Prior Authorization for Antidepressants in Medicaid: Effects Among Disabled Dual Enrollees | Depressive Disorders | JAMA Internal Medicine | JAMA Network
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Original Investigation
April 27, 2009

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

Author Affiliations

Author Affiliations: Kaiser Permanente Division of Research, Oakland, California (Dr Adams); Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts (Drs Adams, Zhang, Ross-Degnan, Lu, Trinacty, and Soumerai, Mr LeCates, and Ms Graves); Jen Associates, Inc, Cambridge, Massachusetts (Mr Gilden); and Department of Pediatrics and Psychiatry, School of Medicine, University of Massachusetts, Worcester (Dr McLaughlin).

Arch Intern Med. 2009;169(8):750-756. doi:10.1001/archinternmed.2009.39

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 state's previous decision to discontinue prior approval for antidepressants in 2003.