Medical and Pharmacy Expenditures After Implementation of a Cyclooxygenase-2 Inhibitor Prior Authorization Program

Gleason, Patrick P.; Williams, Clint E.; Hrdy, Sally; Hartwig, Steven C.; Lassen, David Dreyer

doi:10.1592/phco.2005.25.7.924

Cited by 18 publications

(15 citation statements)

References 17 publications

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“…A comparison group was identified from a different commercially insured BCBS population in the central United States reduced nonpreferred agent utilization and expenditures; however, it was unclear in these studies whether patients were impacted positively or negatively. 4 The PA policies evaluated in the systematic review, [5][6][7][8][9][10][11][12][13] and the studies of PA policies published after the review, consistently focus on the populations with high pharmacy spending. [14][15][16][17][18] For example, Zhang et al reported in 2009 the results of a PA policy among Medicaid and Medicare enrollees affecting second-generation antipsychotics and anticonvulsant medication.…”

Section: ■■ Methodsmentioning

confidence: 99%

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Rosiglitazone Prior Authorization Safety Policy: A Cohort Study

Starner¹,

Fenrick²,

Coleman³

et al. 2012

JMCP

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Section: ■■ Methodsmentioning

confidence: 99%

“…5,6,11,12,17,18,27 These studies have found no increase in medical utilization or costs among individuals denied drug coverage. A commonality of these studies was the nonacuity of the condition for which the medication is generally used.…”

Section: ■■ Conclusionmentioning

confidence: 98%

Rosiglitazone Prior Authorization Safety Policy: A Cohort Study

Starner¹,

Fenrick²,

Coleman³

et al. 2012

JMCP

Self Cite

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“…[16][17][18][19][20][21] A claims analysis reviewing step therapy for antidepressants showed that the days supplied and medication cost decreased, but overall and mental health-related inpatient and emergency room utilization and costs increased for employer plans. 16 A 1998 study found that common utilization management strategies for decreasing drug expenditures (e.g., restrictiveness of formulary) may be associated with higher severity-adjusted resource utilization for select conditions and that this pattern is more pronounced in the elderly.…”

Section: ■■ Conclusionmentioning

confidence: 99%

“…17 However, studies for COX-2 inhibitors show savings in pharmacy expenditure without increases in medical expenditure. [18][19][20][21] To our knowledge, no published studies have examined the impact of utilization management strategies on the use of chronic gout treatment or its effect on overall health care utilization and costs. This is understandable, since treatment options for chronic gout management are limited, and until the introduction of febuxostat, all medications had long been available as generics.…”

Section: ■■ Conclusionmentioning

confidence: 99%

Benefit Restrictions and Gout Treatment

Wang

Aranda²,

Gao³

et al. 2013

JMCP

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BACKGROUND: Gout is a chronic rheumatic disease that can have serious sequelae, including persistent pain, nerve compression, joint destruction and deformities if left untreated. Febuxostat, initially introduced in the United States in 2009, was the first new treatment option for gout in over 40 years. With the introduction of a new drug into a therapeutic class that is composed of generically available options, utilization management will be a common strategy employed in an effort to contain cost; however, the effects of these strategies are not known for chronic gout treatment.

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“…With respect to the former, studies of the impact of PA and step therapy on medical and/or total cost of care (pharmacy and medical cost) have shown mixed results with respect to overall savings. [8][9][10][11][12][13][14][15][16][17] Recently, 2 Pfizer-sponsored retrospective studies examining the association of a pregabalin PA on the total cost of care in a Medicaid and a commercial population were presented to the MCO. [16][17] Because the MCO did not believe that the studied population was representative of its beneficiaries, Pfizer and impact of a PA on pregabalin, not a direct comparison of treatment effects of specific medications.…”

Section: A Case Study In Neuropathic Painmentioning

confidence: 99%

Developing a Collaborative Study Protocol for Combining Payer-Specific Data and Clinical Trials for CER

Sanchez¹,

Mardekian²,

Cziraky³

et al. 2011

JMCP

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T he demand for comparative effectiveness research (CER) by health care providers and payers represents new opportunities for the U.S. government, research organizations, and pharmaceutical companies to generate "meaningful evidence" for use in medical decision making.1 CER studies conducted with a payer perspective should develop questions, select outcomes, and utilize data that are applicable to the payers themselves for use with their formulary and reimbursement decision-making processes. CER studies for prescribers should be designed and implemented to inform evidence-based therapeutic guidelines, providing actionable information from their everyday practice use. The challenge is how to conduct CER studies that satisfy the simultaneous requirements of scientific rigor and applicability to the respective decision makers. One solution is to address the demand for "real-world" data (RWD) by involving decision makers and other key stakeholders early on in the development of the research designs and implementation of study protocols when conducting CER studies. RWD have been defined "as data used for decision-making that are not collected in conventional RCTs" (randomized controlled trials); 2 therefore, the ability to gather input from the payer is essential to ensure collected endpoints are applicable to the decision makers themselves.RCTs are considered the "gold standard" for providing evidence about a product's efficacy and are the basis for supporting formulary decision making. While the internal validity of RCTs is well known and established, the controlled protocols of RCTs may not have the desired level of external validity for a managed care organization's (MCO) population. Consequently, health care decision makers are examining other sources of data to supplement RCTs for their health care coverage policies. Health care providers and payers use available evidence from both RCTs and RWD sources to decide whether a particular drug product offers tangible clinical benefits and value compared with existing therapies. Improving medical outcomes and providing positive impact on health care expenditures are shared goals of providers, payers, and the pharmaceutical industry. 3Developing CER Studies to Inform Payer Decision Making Payers are interested in CER results and evidence-based value assessments of comparator therapies to use in their coverage decision-making processes. Some have proposed that CER involving systematic reviews of effectiveness evidence could improve the coverage and reimbursement processes. 4 However, now more than ever, there is a need for better evidence generation rather than just better synthesis of existing evidence, which raises the question of how more meaningful evidence could be generated and how the decision makers could be involved in the identification of evidence gaps, design of study protocols, and implementation of CER studies, particularly those that propose to use RWD. It also is important to determine when additional studies, and related designs, are needed; value of in...

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Medical and Pharmacy Expenditures After Implementation of a Cyclooxygenase-2 Inhibitor Prior Authorization Program

Abstract: Among members denied coverage for a COX-2 inhibitor after implementation of a PA program, pharmacy costs declined without a medical cost increase associated with gastrointestinal diagnoses.

Cited by 18 publications

References 17 publications

Rosiglitazone Prior Authorization Safety Policy: A Cohort Study

Rosiglitazone Prior Authorization Safety Policy: A Cohort Study

Benefit Restrictions and Gout Treatment

Developing a Collaborative Study Protocol for Combining Payer-Specific Data and Clinical Trials for CER

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