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1.
J Manag Care Spec Pharm ; 30(5): 507-513, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38651983

RESUMO

Prescription drug contracting in the United States has evolved over decades from discounts provided to members of early health maintenance organization plans to rebate contracts to more complex value-based purchasing arrangements. This primer describes the history of contracting between pharmaceutical manufacturers and managed care pharmacy organizations and details the various contracting methods used today.


Assuntos
Indústria Farmacêutica , Medicamentos sob Prescrição , Medicamentos sob Prescrição/economia , Estados Unidos , Humanos , Indústria Farmacêutica/economia , Programas de Assistência Gerenciada/economia , Contratos , Assistência Farmacêutica/organização & administração , Assistência Farmacêutica/economia
2.
Curr Med Res Opin ; 38(9): 1621-1630, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-35833696

RESUMO

BACKGROUND: Long-acting injectable antipsychotics (LAIs) may reduce hospitalizations versus oral formulations (OAP) in bipolar disorder (BP) and schizophrenia/schizoaffective disorder (SCZ), but the impact on time to outpatient follow-up is less understood. OBJECTIVES: To assess hospital readmissions and medical costs among Medicaid beneficiaries with BP or SCZ utilizing OAP or LAI SGAs. METHODS: Cross-sectional and longitudinal analyses utilized comprehensive administrative claims of Oklahoma Medicaid beneficiaries (≥18 years) with BP or SCZ between 1 January 2013 and 31 December 2017. Readmissions, total direct medical costs, and psychiatry-related outpatient visits were assessed via generalized linear models and generalized estimating equations, controlling for demographic and clinical covariates. RESULTS: Among 2523 included members, LAI utilization was associated with 1.50 and 1.73 times higher odds of any hospitalization and any readmission, respectively (p < .05). Cases involving both BP and SCZ were associated with a 2.40 times higher odds of any readmission, 2.26 times higher number of readmissions, and 24.5% higher costs (p < .001). Of the 468 members with a subsequent psychiatry-related outpatient visit, LAIs were associated with a 23.9% shorter duration to outpatient visit and 16.4% lower costs (p < .05). CONCLUSION: In contrast to prior studies, this real-world investigation noted higher hospitalizations and readmissions among LAIs relative to OAP medications, but among members with a hospitalization or ED visit, LAIs were associated with shorter durations to outpatient visits and lower costs. Those with diagnoses of both BP with SCZ had higher odds of any readmission, number of readmissions, and costs relative to those with bipolar disorder alone and may be a key target for interventions.


This study compared long-acting antipsychotics that were administered by injection (LAIs) to antipsychotic agents taken orally (OAPs) among Medicaid members with bipolar disorder and/or schizophrenia. Readmission to the emergency department (ED) or hospital (within 30 days of a previous visit) and costs were observed to be similar with LAIs relative to OAPs. Among members who went to the hospital, a shorter time to psychiatric follow-up outpatient visit and lower costs were observed among those taking LAIs relative to OAPs.


Assuntos
Antipsicóticos , Transtorno Bipolar , Esquizofrenia , Administração Oral , Antipsicóticos/uso terapêutico , Transtorno Bipolar/tratamento farmacológico , Estudos Transversais , Preparações de Ação Retardada/uso terapêutico , Hospitais , Humanos , Injeções , Medicaid , Pacientes Ambulatoriais , Alta do Paciente , Readmissão do Paciente , Estados Unidos
3.
J Gen Intern Med ; 35(11): 3188-3196, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32935311

RESUMO

BACKGROUND: A large proportion of individuals who use heroin report initiating opioid use with prescription opioids. However, patterns of prescription opioid use preceding heroin-related overdose have not been described. OBJECTIVE: To describe prescription opioid use in the year preceding heroin overdose. DESIGN: Case-control study comparing prescription opioid use with a heroin-involved overdose, non-heroin-involved opioid overdose, and non-overdose controls from 2015 to 2017. PARTICIPANTS: Oregon Medicaid beneficiaries with linked administrative claims, vital statistics, and prescription drug monitoring program data. MAIN MEASURES: Opioid, benzodiazepine, and other central nervous system depressant prescriptions preceding overdose; among individuals with one or more opioid prescription, we assessed morphine milligram equivalents per day, overlapping prescriptions, prescriptions from multiple prescribers, long-term use, and discontinuation of long-term use. KEY RESULTS: We identified 1458 heroin-involved overdoses (191 fatal) and 2050 non-heroin-involved opioid overdoses (266 fatal). In the 365 days prior to their overdose, 45% of individuals with a heroin-involved overdose received at least one prescribed opioid compared with 78% of individuals who experienced a non-heroin-involved opioid overdose (p < 0.001). For both heroin- and non-heroin-involved overdose cases, the likelihood of receiving an opioid increased with age. Among heroin overdose cases with an opioid dispensed, the rate of multiple pharmacy use was the only high-risk opioid pattern that was greater than non-overdose controls (adjusted odds ratio 3.2; 95% confidence interval 1.48 to 6.95). Discontinuation of long-term opioid use was not common prior to heroin overdose and not higher than discontinuation rates among non-overdose controls. CONCLUSIONS: Although individuals with a heroin-involved overdose were less likely to receive prescribed opioids in the year preceding their overdose relative to non-heroin opioid overdose cases, prescription opioid use was relatively common and increased with age. Discontinuation of long-term prescription opioid use was not associated with heroin-involved overdose.


Assuntos
Analgésicos Opioides , Overdose de Drogas , Analgésicos Opioides/uso terapêutico , Estudos de Casos e Controles , Overdose de Drogas/tratamento farmacológico , Overdose de Drogas/epidemiologia , Heroína , Humanos , Medicaid , Oregon/epidemiologia , Prescrições , Estados Unidos/epidemiologia
4.
J Am Pharm Assoc (2003) ; 60(5S): S7-S10, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32669218

RESUMO

OBJECTIVES: Bring awareness of the health disparity of higher psychotropic medication use among foster youth, describe barriers to optimizing foster children's medication regimen from the perspective of people who work closely with them, and propose practical strategies to empower pharmacists to identify and care for this vulnerable population. SUMMARY: A total of 11 focus groups with 72 participants were conducted. Although the discussion guide did not specifically address pharmacists or pharmacies, participants in 9 groups referenced them. The pharmacist-related comments fell under 2 main themes: (1) Pharmacists are recognized as medication experts and their expertise is valued. (2) Those caring for foster youth observe barriers to optimal medication therapy that are unique to children in the foster care system. Practical considerations include providing education to social workers, offering unit-dose packaging, offering delivery, and being a resource during transitions of care. CONCLUSION: Higher rates of psychotropic medication use among foster youth in the United States have raised concern for several decades. Pharmacists are recognized as medication experts by the foster care team, creating an opportunity for pharmacists to become more involved in optimizing psychotropic medication use among foster youth.


Assuntos
Criança Acolhida , Farmácias , Adolescente , Criança , Cuidados no Lar de Adoção , Humanos , Farmacêuticos , Psicotrópicos/uso terapêutico , Estados Unidos
5.
J Manag Care Spec Pharm ; 25(12): 1340-1348, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31778625

RESUMO

BACKGROUND: Foster youth have higher rates of psychotropic medication use and concurrent multiclass psychotropic polypharmacy compared with nonfoster youth. However, less is known about the extent of multiclass psychotropic polypharmacy after adjusting for patient factors associated with psychotropic medication use OBJECTIVES: To (a) compare psychotropic medication use and psychotherapy use by youth in foster care to those not in foster care in the Oklahoma Medicaid population across various sociodemographic and clinical factors, and (b) determine if patient-related characteristics are associated with high levels of concurrent multiclass psychotropic polypharmacy. METHODS: This cross-sectional, retrospective analysis was conducted using paid prescription, outpatient, and inpatient Oklahoma Medicaid administrative claims from calendar year 2016. Foster youth and adolescents aged 20 years or younger were identified (n = 9,325) and compared with the general Oklahoma Medicaid population of the same age (n = 639,868). Descriptive statistics highlight baseline demographic and clinical differences between the 2 groups. Multivariable logistic regression was used to determine if covariates were associated with concurrent multiclass psychotropic polypharmacy. A subgroup analysis of foster youth taking at least 1 psychotropic medication was also performed to determine factors associated with the highest level of concurrent multiclass psychotropic polypharmacy. RESULTS: Foster care was associated with higher odds of concurrent multiclass psychotropic polypharmacy regardless of presence of psychotherapy. Among the subgroup of foster youth taking at least 1 psychotropic medication, attention deficit hyperactivity disorder medications were the most commonly prescribed medication class, followed by antidepressants and anxiolytics when use was not chronic. However, at the highest level of chronic multiclass psychotropic polypharmacy (4-5 chronic concurrent medications), antipsychotics rose to the top, and anxiolytics were the least likely to be prescribed. Overall, the foster care population had the highest proportion of individuals with concurrent multiclass psychotropic polypharmacy (9.2% vs. 1.9%, P < 0.0001). The highest level of chronic multiclass psychotropic polypharmacy was more likely to occur in males (OR = 1.66, 95% CI = 1.40-1.96) and patients living in group homes (OR = 4.13, 95% CI = 2.02-8.44) or foster homes (OR = 1.66, 95% CI = 1.25-2.19). Being overweight or obese was associated with an 83% higher odds of being at the highest level of concurrent multiclass psychotropic polypharmacy (95% CI = 1.27-2.64). CONCLUSIONS: Despite higher psychotherapy use, high rates of psychotropic medication use and concurrent multiclass psychotropic polypharmacy in foster youth remain a concern for policymakers. Patterns observed at different levels of concurrent multiclass psychotropic polypharmacy may be key to identifying youth who require additional monitoring. Future research exploring factors associated with higher levels of psychotropic concurrent multiclass psychotropic polypharmacy in foster youth can lead to actionable interventions and important policy changes. DISCLOSURES: This project was funded through the CHIP Health Services Initiative. Keast, Tidmore, and Lambert report contractual employment for the Oklahoma Health Care Authority. Nesser is an employee of the Oklahoma Health Care Authority, and Shropshire is an employee of the Oklahoma Department of Human Services. Keast discloses unrelated research grant funding from AbbVie, Amgen, Otsuka, and Purdue Pharma. Tidmore discloses unrelated research grant funding from Amgen and Otsuka. The remaining authors have no relevant disclosures or conflicts of interest to declare. Posters based on this study were presented at AMCP Nexus 2017; October 16-19, 2017; Grapevine, TX, and at the AMCP Annual Meeting 2018; April 23-26, 2018; Boston, MA.


Assuntos
Criança Acolhida/estatística & dados numéricos , Psicoterapia/estatística & dados numéricos , Psicotrópicos/uso terapêutico , Adolescente , Adulto , Antidepressivos/uso terapêutico , Antipsicóticos/uso terapêutico , Criança , Pré-Escolar , Estudos Transversais , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Medicaid/estatística & dados numéricos , Oklahoma , Polimedicação , Medicamentos sob Prescrição/uso terapêutico , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
6.
J Manag Care Spec Pharm ; 25(11): 1261-1267, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31663456

RESUMO

BACKGROUND: Newer hepatitis C virus (HCV) treatments often provide high success rates with fewer adverse events, although the extent of all potential drug interactions is not fully known. OBJECTIVE: To assess outcomes of receiving HCV treatment and subsequent sustained virologic response (SVR) based on patient and clinical characteristics, including direct-acting antiviral (DAA) drug-drug interactions (DDIs), in Medicaid members with chronic HCV. METHODS: Comprehensive medical and pharmacy claims and prior authorization data were collected for HCV patients requesting treatment between January 2014 and June 2015. Outcomes of receiving treatment with DAAs and treatment failure based on SVR were analyzed according to demographics, prior/current HCV treatment, severity of DDIs, advancing liver disease, and comorbidities. Multivariable generalized linear models were employed, including a Bayesian sensitivity analysis. RESULTS: Among 3,412 Medicaid members with HCV, 13.6% received DAAs (n = 464), averaging 53.6 ± 10.0 years, with 52.8% female. Multivariable analyses indicated that higher odds of DAA treatment initiation were associated with older age, prior HCV treatment, and advancing liver disease. Some 4.8% of treatment failures occurred among 168 patients with reported SVRs, wherein a 3.218 times higher adjusted odds of treatment failure was associated with concomitant use of medications with DDIs classified as significant or potentially clinically significant by the University of Liverpool HEP Drug Interactions resource (P = 0.001). CONCLUSIONS: In a cohort of state Medicaid members with chronic HCV, a markedly higher adjusted odds of treatment failure was independently associated with DDIs classified as significant or potentially clinically significant, warranting continued inquiry and potential alternate treatments concerning conditions that require their use. DISCLOSURES: This research was funded by an unrestricted research grant by Gilead Sciences. During the course of this study, all authors were either employed by the Oklahoma HealthCare Authority or engaged in contractual work for this employer. Keast, Holderread, and Skrepnek report unrelated research grants from AbbVie, Otsuka, and Amgen. Keast and Skrepnek acknowledge funding from Purdue Pharma for an unrelated research fellowship grant. Posters based on this work were presented at HepDart 2015 on December 6-10, 2015, in Grand Wailea, HI, and at Academy of Managed Care Nexus 2015 on October 26-29, 2015, in Orlando, FL.


Assuntos
Antivirais/uso terapêutico , Hepacivirus/efeitos dos fármacos , Hepatite C Crônica/tratamento farmacológico , Medicaid/organização & administração , Conduta do Tratamento Medicamentoso/organização & administração , Adulto , Antivirais/farmacologia , Teorema de Bayes , Estudos Transversais , Interações Medicamentosas , Feminino , Hepacivirus/isolamento & purificação , Hepatite C Crônica/virologia , Humanos , Masculino , Pessoa de Meia-Idade , Oklahoma , Resposta Viral Sustentada , Falha de Tratamento , Estados Unidos
7.
J Eval Clin Pract ; 25(5): 806-821, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30485617

RESUMO

RATIONALE, AIMS, AND OBJECTIVES: To assess inpatient clinical and economic outcomes for AIDS/HIV and Hepatitis C (HCV) co-infection in the United States from 2003 to 2014. METHOD: This historical cohort study utilized nationally representative hospital discharge data to investigate inpatient mortality, length of stay (LoS), and inflation-adjusted charges among adults (≥18 years). Outcomes were analysed via multivariable generalized linear models according to demographics, hospital and clinical characteristics, and AIDS/HIV or HCV sequelae. RESULTS: Overall, 17.8% of the 2.75 million estimated AIDS/HIV inpatient cases involved HCV from 2003 to 2014, averaging 48.5 ± 9.0 years of age and 68.0% being male. Advanced sequalae of AIDS and HCV incurred a LoS of 10.3 ± 11.9 days, charges of $88 789 ± 131 787, and a 16.9% mortality. Many cases involved noncompliance, tobacco use disorders, and substance abuse. Although mortality decreased over time, multivariable analyses indicated that poorer outcomes were generally associated with more advanced clinical conditions and AIDS-associated sequalae, although mixed results were observed for specific manifestations of HCV. Rural residence was independently associated with a 3.26 times higher adjusted odds of mortality from 2009 to 2014 for HIV/HCV co-infection (P < 0.001), although not for AIDS/HCV (OR = 1.38, P = 0.166). CONCLUSION: Given the systemic nature and modifiable risks inherent within coinfection, more proactive screening and intervention appear warranted, particularly within rural areas.


Assuntos
Síndrome da Imunodeficiência Adquirida , Coinfecção , Infecções por HIV , Hepatite C , Hospitalização , Síndrome da Imunodeficiência Adquirida/economia , Síndrome da Imunodeficiência Adquirida/mortalidade , Síndrome da Imunodeficiência Adquirida/terapia , Estudos de Coortes , Coinfecção/economia , Coinfecção/mortalidade , Coinfecção/terapia , Grupos Diagnósticos Relacionados/economia , Grupos Diagnósticos Relacionados/estatística & dados numéricos , Feminino , Infecções por HIV/economia , Infecções por HIV/mortalidade , Infecções por HIV/terapia , Hepatite C/economia , Hepatite C/mortalidade , Hepatite C/terapia , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Avaliação das Necessidades , Avaliação de Resultados em Cuidados de Saúde/métodos , Estados Unidos/epidemiologia
8.
J Am Pharm Assoc (2003) ; 59(1): 121-124, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30528252

RESUMO

OBJECTIVES: To describe roles for pharmacists to facilitate payer-initiated value-based contracts within state Medicaid programs. SUMMARY: According to the Centers for Medicare and Medicaid Services, prescription drug expenditures are expected to see the fastest annual growth in the health care sector over the next decade owing to a greater number of costly specialty medications and overall higher drug prices. Increased prescription costs make value-based contracts particularly compelling opportunities for payers. Pharmacists, as formulary subject-matter experts, have unique skills that are beneficial to value-based contract designs. Much like their role in formulary development, pharmacists' clinical knowledge of evidence-based medicine and cost-effective medication use ensures that contract negotiations are both clinically appropriate and address cost-savings components. Well designed value-based contracts can potentially improve the quality of care without increasing overall health care expenditures. Other potential benefits of value-based contracts include reducing waste, achieving cost predictability, and achieving fiscal responsibility for high-cost drugs while supporting patient access.


Assuntos
Custos de Medicamentos , Medicaid/economia , Farmacêuticos/economia , Mecanismo de Reembolso/economia , Contratos , Humanos , Estados Unidos
9.
J Am Pharm Assoc (2003) ; 58(5): 485-491, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30033127

RESUMO

OBJECTIVES: The market for chronic hepatitis C (HCV) treatment has changed rapidly. New treatments offer high cure rates, fewer adverse effects, and shorter treatments-but also increased costs per therapy. The objective of this study was to compare adherence and cost between HCV patients included in an enhanced prior authorization and management program (PAMP) versus no intervention in Medicaid members undergoing treatment. DESIGN: A retrospective study using longitudinal panel data assessed differences in adherence and costs associated with implementation of the PAMP from the payer perspective. The PAMP included case management, patient education, pharmacy counseling, and medication adherence. Multivariable generalized estimating equations were used to assess associations between program and outcomes. SETTING AND PARTICIPANTS: Patients with HCV enrolled in a state Medicaid program receiving or requesting HCV treatment from January 2014 to November 2015. OUTCOME MEASURES: Outcomes included medication adherence, treatment gaps, and pharmacy and total direct costs after controlling for demographic and clinical factors between those in the PAMP and those in the preintervention period. RESULTS: There were 384 Medicaid members included (156 pre-PAMP, 228 post-PAMP). Overall adherence was high regardless of PAMP intervention, although an adjusted 1.086-fold increase in medication possession ratio (MPR) was observed with the program and a 2.732-fold higher odds of adherence above 80% (P < 0.05). Members in the program had 0.358 times lower adjusted odds of a greater than 3-day treatment gap, and pharmacy-related costs were 0.940 times lower (P < 0.05); no difference was observed in total medical costs (P = 0.333). CONCLUSION: This enhanced Medicaid program was associated with increased adherence to HCV therapy, decreased treatment gaps, and decreased pharmacy-related costs compared with the preintervention period. Because challenges exist if patients fail HCV treatment or if viral resistance emerges, ensuring high adherence and persistence remains key. Continued work is needed to develop and assess enhanced management programs for this population.


Assuntos
Custos de Medicamentos/estatística & dados numéricos , Hepatite C Crônica/economia , Adesão à Medicação/estatística & dados numéricos , Conduta do Tratamento Medicamentoso/economia , Autorização Prévia/economia , Serviços Comunitários de Farmácia/economia , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Farmacêuticos , Estudos Retrospectivos , Estados Unidos
10.
Med Care ; 56(8): 727-735, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29995696

RESUMO

BACKGROUND: Medicaid members are predisposed to unintentional prescription opioid overdose. However, little is known about their individual risk factors. OBJECTIVES: To describe demographic and clinical characteristics, medical utilization, opioid use, concurrent use of benzodiazepines, risk factors, and substances involved in death for Oklahoma's Medicaid members who died of unintentional prescription opioid poisoning. SUBJECTS: Decedents who were Medicaid eligible in Oklahoma during the year of death, had an opioid recorded in cause of death, and had ≥1 opioid prescription claim between January 1, 2011 and June 30, 2016 were cases. Controls were living Medicaid members and were matched 3:1 to cases through propensity score matching. MEASURES: Demographics, clinical characteristics, and medical/pharmacy utilization were examined in the 12 months before the index date. RESULTS: Of 639 members with fatal unintentional prescription opioid overdoses, 321 had ≥1 opioid prescription claim in the year before death; these were matched to 963 controls. Compared with controls, decedents had significantly greater proportions of nonopioid substance use disorders, opioid abuse/dependence, hepatitis, gastrointestinal bleeding, trauma not involving motor vehicle accidents, nonopioid poisonings, and mental illness disorders. Decedents had significantly higher daily morphine milligram equivalent doses (67.2±74.4 vs. 47.2±50.9 mg) and greater opioid/benzodiazepine overlap (70.4% vs. 35.9%). Benzodiazepines were involved in 29.3% of deaths. CONCLUSIONS: Several comorbidities indicative of opioid use disorder and greater exposure to opioids and concomitant benzodiazepines were associated with unintentional prescription opioid overdose fatalities. Prescribers and state agencies should be aware of these addressable patient-level factors among the Medicaid population. Targeting these factors with appropriate policy interventions and education may prevent future deaths.


Assuntos
Analgésicos Opioides/intoxicação , Overdose de Drogas/mortalidade , Prescrições de Medicamentos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/mortalidade , Uso Indevido de Medicamentos sob Prescrição/mortalidade , Medicamentos sob Prescrição/intoxicação , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oklahoma/epidemiologia
11.
J Manag Care Spec Pharm ; 24(7): 664-676, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29952711

RESUMO

BACKGROUND: Outcomes involving newer direct-acting antiviral (DAA) hepatitis C virus (HCV) regimens have not been studied extensively among the Medicaid population. OBJECTIVE: To assess clinical (treatment failure) and economic outcomes for chronic HCV-infected Oklahoma Medicaid members following treatment with DAAs and to measure associations with patient, treatment, and clinical characteristics. METHODS: This cross-sectional study used Oklahoma Medicaid pharmacy and medical claims data for adult members who used a newer DAA agent and had reported a successful or failed sustained virological response rate 12 weeks after therapy completion (SVR12) from January 1, 2014, to June 30, 2016. Multivariable logistic and gamma regressions assessed predictors of SVR12 failure and costs controlling for member demographics (i.e., age, sex, race, rural residence); type of DAA and adherence; clinical characteristics (e.g., comorbid conditions, advanced liver disease); and the implementation of changes to a prior authorization program. RESULTS: Of 934 Medicaid members eligible for treatment with DAAs between January 1, 2014, and June 30, 2016, 906 received DAA treatment, 40.6% (368/906) had reported SVR12 outcomes, and 59.4% (n = 538) did not have a reported SVR recorded. Of those with reported SVR12 outcomes, patients were 53.1 ± 9.7 years of age, 51.1% were male, 8.4% had SVR12 failure, and each member had mean costs of $140,283 ± $52,779. Multivariable analyses indicated higher odds of SVR12 failure was independently associated with cirrhosis (OR [decompensated] = 6.69 and OR [compensated] = 3.52, P < 0.001), while males had higher odds of failure than females (OR = 3.34, P < 0.010). No significant difference in SVR12 failure was noted, according to DAA type or a medication adherence threshold of > 95%. Ledipasvir/sofosbuvir was independently associated with lower costs (exp[b] = 0.81; P < 0.001) compared with sofosbuvir, while higher costs were associated with decompensated cirrhosis (exp[b] = 1.22; P < 0.001) and treatment failure (exp[b] = 1.18, P < 0.010). In an analysis including members without reported SVR12 outcomes, decompensated and compensated cirrhosis had lower odds (P < 0.001) of no reported SVR12 from ambulatory clinic settings. CONCLUSIONS: Almost 60% of Medicaid members receiving DAA treatment did not have a final reported SVR12 outcome. Among those with viral load measurements, treatment success was high and both decompensated and compensated cirrhosis were independently associated with significantly higher odds of treatment failure. Addressing a loss to follow-up among HCV patients and curtailing the development of cirrhosis to improve treatment success may warrant interventions that improve access to care and remove barriers that impede treatment initiation and completion. DISCLOSURES: No outside funding supported this study. Pham, Keast, Holderread, Nesser, and Skrepnek disclose either employment by the Oklahoma Health Care Authority or contractual work for this employer. Pham discloses fellowship funding from Purdue Pharma unrelated to this study. Keast and Skrepnek disclose research grant funding from Gilead Sciences and Abbvie. Holderread also reports grant funding from Gilead Sciences and fees from PRIME Education. Thompson, Farmer, and Rathbun have nothing to disclose.


Assuntos
Antivirais/uso terapêutico , Hepacivirus/efeitos dos fármacos , Hepatite C Crônica/economia , Cirrose Hepática/economia , Medicaid/economia , Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Adulto , Antivirais/economia , Estudos de Coortes , Efeitos Psicossociais da Doença , Estudos Transversais , Custos de Medicamentos/estatística & dados numéricos , Quimioterapia Combinada/economia , Quimioterapia Combinada/métodos , Feminino , Genótipo , Hepacivirus/isolamento & purificação , Hepatite C Crônica/tratamento farmacológico , Hepatite C Crônica/virologia , Humanos , Cirrose Hepática/tratamento farmacológico , Cirrose Hepática/virologia , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Oklahoma , Assistência Farmacêutica/estatística & dados numéricos , Resposta Viral Sustentada , Falha de Tratamento , Estados Unidos
12.
J Am Pharm Assoc (2003) ; 58(3): 296-302, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29402662

RESUMO

OBJECTIVES: To use a pharmacist-managed short-acting beta agonist (SABA) service (1) to determine the patient's rationale for SABA refill requests, (2) to assess adherence to current controller therapy and current level of disease control, and (3) to characterize the pharmacist's recommendations made in response to a patient's SABA refill request. SETTING: An academic-based general pediatric clinic. PRACTICE DESCRIPTION: SABA overuse is a marker of increased morbidity and mortality in children with asthma. This article describes a pharmacist-managed SABA refill telephone service. PRACTICE INNOVATION: The pediatric ambulatory care pharmacy team assessed and authorized (or denied) all SABA refill requests, provided education, and facilitated appropriate follow-up using a telephone service. INTERVENTIONS: Upon receiving a patient-requested SABA refill, the pharmacist identified the reason for the SABA request, assessed asthma control, and determined adherence to daily controllers or spacer use, if applicable. Education was also provided. Data obtained were used to determine SABA refill approval. EVALUATION: Primary reasons for SABA refill request were for (1) current symptom management and (2) no refills remaining in the absence of symptoms. Forty-two (50%) SABA refill requests were eligible for refill per the clinic algorithm, yet 70% actually received a refill after assessment by the pharmacist. Asthma control was assessed as 26% well controlled, 38% not well controlled, and 36% very poorly controlled. Forty-eight percent of patients prescribed daily controller medications were deemed adherent. Spacers were used in 43 of 76 (56%) patients using metered dose inhalers. Education was provided to 82% of caregivers. Pharmacists facilitated asthma follow-up visits in 41 of 84 (49%) patients contacted, and 61% of those appointments were kept. CONCLUSIONS: Pharmacist management of a SABA refill telephone service provides an additional means for delivery of asthma education, facilitates follow-up asthma care, helps to identify patients at risk for increased morbidity and mortality due to the overuse of SABAs, and provides another mechanism for medication refills.


Assuntos
Agonistas Adrenérgicos beta/administração & dosagem , Assistência Farmacêutica/organização & administração , Farmacêuticos/organização & administração , Instituições de Assistência Ambulatorial/organização & administração , Asma/tratamento farmacológico , Criança , Prescrições de Medicamentos , Feminino , Humanos , Masculino , Farmácias/organização & administração , Atenção Primária à Saúde/organização & administração
13.
Subst Abus ; 39(2): 239-246, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29016245

RESUMO

BACKGROUND: High dosage opioid use is a risk factor for opioid-related overdose commonly cited in guidelines, recommendations, and policies. In 2012, the Oregon Medicaid program developed a prior authorization policy for opioid prescriptions above 120 mg per day morphine equivalent dose (MED). This study aimed to evaluate the effects of that policy on utilization, prescribing patterns, and health outcomes. METHODS: Using administrative claims data from Oregon and a control state (Colorado) between 2011 and 2013, we used difference-in-differences analyses to examine changes in utilization, measures of high risk opioid use, and overdose after introduction of the policy. We also evaluated opioid utilization in a cohort of individuals who were high dosage opioid users before the policy. RESULTS: Following implementation of Oregon's high dosage policy, the monthly probability of an opioid fill over 120 mg MED declined significantly by 1.7 percentage points (95% confidence interval [CI]; -2.0% to -1.4%), whereas it increased significantly by 1.0 percentage points (95% CI 0.4% to 1.7%) for opioid fills < 61 mg MED. Fills of medications used to treat neuropathic pain also increased by 1.2 percentage points (95% CI 0.7% to 1.8%). The monthly probability of multiple pharmacy use declined by 0.1 percentage points (-0.2% to -0.0) following the prior authorization, but there were no significant changes in ED encounters or hospitalizations for opioid overdose. Among individuals who were using a high dosage opioid before the policy, there was a 20.3 percentage point (95% CI -15.3% to -25.3%) decline in estimated probability of having a high dosage fill after the policy. CONCLUSIONS: Oregon's prior authorization policy was effective at reducing high dosage opioid prescriptions. While multiple pharmacy use also declined, we found no impact on opioid overdose were observed.


Assuntos
Overdose de Drogas/epidemiologia , Uso de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Uso Indevido de Medicamentos sob Prescrição/estatística & dados numéricos , Autorização Prévia , Adulto , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Colorado/epidemiologia , Feminino , Humanos , Masculino , Oregon/epidemiologia , Adulto Jovem
14.
J Manag Care Spec Pharm ; 23(8): 875-883, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28737989

RESUMO

BACKGROUND: Patient review and restriction programs (PRRPs), used by state Medicaid programs to limit potential abuse and misuse of opioids and related controlled medications, often restrict members to a single pharmacy for controlled medications. While most states use a restricted pharmacy access model, not all states include restricted prescriber access. Oklahoma Medicaid (MOK) added a restricted prescriber access feature to its PRRP in July 2014. OBJECTIVE: To evaluate the incremental effect that the addition of a prescriber restriction to MOK's pharmacy-only PRRP had on the pharmacy and resource utilization of the enrolled members. METHODS: MOK members with at least 6 months of enrollment in the pharmacy-only PRRP were restricted to a maximum of 3 prescribers for controlled substances in July 2014 and were identified as "cases." Using a propensity score method, cases were matched to controls from the MOK non-PRRP enrolled population based on demographics and baseline health care utilization. Data from January 1, 2014, through December 31, 2014, were evaluated. Each member's monthly health care resource utilization, defined in terms of medical and pharmacy costs, prescription counts, and opioid use per member per month (PMPM), was analyzed. A difference-indifferences (DID) regression estimated the change in resource utilization following the July 2014 policy change. RESULTS: This study included 378 controls and 126 cases after propensity matching. No differences were noted for daily morphine equivalents, benzodiazepine prescriptions, or maintenance prescriptions. There were decreases in mean PMPM use for both groups for short-acting opioid (SAO) claims (P < 0.001), overall opioid claims (P = 0.007 for controls and P < 0.001 for cases), prescribers (P = 0.01 for controls and P < 0.001 for cases), and number of pharmacies for cases (P < 0.001). DID analyses indicated that cases had a larger decrease in mean SAO claims (difference: -0.15, 95% CI: -0.25 to -0.04, P = 0.008); prescribers (difference: -0.25, 95% CI: -0.36 to -0.15, P < 0.001); and pharmacies (difference: -0.20, 95% CI: -0.28 to -0.13, P < 0.001) relative to controls. The difference for overall opioid claims was greater for cases than controls but did not reach statistical significance (difference: -0.12, 95% CI: -0.25 to 0.00, P = 0.050). CONCLUSIONS: Although there was no evidence that overall opioid claims were affected, the addition of prescriber restrictions may have resulted in an incremental change to SAO, prescriber, and pharmacy use in the PRPP population. Use of PRRPs may be an effective tool in reducing inappropriate use of prescription opioids within payer systems. The question remains whether these changes result in long-term changes to behavior outside the payer system. Future research into the effects of PRRPs on patient behavior beyond the payer system is needed. DISCLOSURES: No outside funding supported this research. All authors disclose either employment by the Oklahoma Health Care Authority or contractual work for this employer. In addition, Keast discloses unrelated funding through unrestricted research grants from Gilead Sciences and Purdue Pharma. Study concept and design were contributed by Keast and Pham, along with Teel and Nesser. Keast and Pham collected the data, along with Teel, and data interpretation was provided by Keast and Pham, with assistance from Teel and Nesser. The manuscript was written primarily by Keast, along with Pham and Teel, and revised by all the authors.


Assuntos
Analgésicos Opioides/economia , Medicaid/economia , Transtornos Relacionados ao Uso de Opioides/economia , Assistência Farmacêutica/economia , Farmácias/economia , Uso Indevido de Medicamentos sob Prescrição/economia , Adulto , Analgésicos Opioides/uso terapêutico , Substâncias Controladas/economia , Feminino , Humanos , Masculino , Oklahoma , Aceitação pelo Paciente de Cuidados de Saúde , Farmácia/métodos , Padrões de Prática Médica/economia , Medicamentos sob Prescrição/economia , Medicamentos sob Prescrição/uso terapêutico , Estados Unidos
15.
Pharmacoepidemiol Drug Saf ; 26(9): 1053-1060, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28722211

RESUMO

BACKGROUND: Out-of-pocket payment for prescription opioids is believed to be an indicator of abuse or diversion, but few studies describe its epidemiology. Prescription drug monitoring programs (PDMPs) collect controlled substance prescription fill data regardless of payment source and thus can be used to study this phenomenon. OBJECTIVE: To estimate the frequency and characteristics of prescription fills for opioids that are likely paid out-of-pocket by individuals in the Oregon Medicaid program. RESEARCH DESIGN: Cross-sectional analysis using Oregon Medicaid administrative claims and PDMP data (2012 to 2013). SUBJECTS: Continuously enrolled nondually eligible Medicaid beneficiaries who could be linked to the PDMP with two opioid fills covered by Oregon Medicaid. MEASURES: Patient characteristics and fill characteristics for opioid fills that lacked a Medicaid pharmacy claim. Fill characteristics included opioid name, type, and association with indicators of high-risk opioid use. RESULTS: A total of 33 592 Medicaid beneficiaries filled a total of 555 103 opioid prescriptions. Of these opioid fills, 74 953 (13.5%) could not be matched to a Medicaid claim. Hydromorphone (30%), fentanyl (18%), and methadone (15%) were the most likely to lack a matching claim. The 3 largest predictors for missing claims were opioid fills that overlapped with other opioids (adjusted odds ratio [aOR] 1.37; 95% confidence interval [CI], 1.34-1.4), long-acting opioids (aOR 1.52; 95% CI, 1.47-1.57), and fills at multiple pharmacies (aOR 1.45; 95% CI, 1.39-1.52). CONCLUSIONS: Prescription opioid fills that were likely paid out-of-pocket were common and associated with several known indicators of high-risk opioid use.


Assuntos
Analgésicos Opioides/efeitos adversos , Gastos em Saúde/tendências , Medicaid/tendências , Uso Indevido de Medicamentos sob Prescrição/tendências , Programas de Monitoramento de Prescrição de Medicamentos/tendências , Estatística como Assunto/tendências , Adolescente , Adulto , Idoso , Analgésicos Opioides/economia , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Masculino , Medicaid/economia , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/economia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Oregon/epidemiologia , Uso Indevido de Medicamentos sob Prescrição/economia , Estatística como Assunto/métodos , Estados Unidos/epidemiologia , Adulto Jovem
16.
J Manag Care Spec Pharm ; 22(2): 145-8, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27015253

RESUMO

Rising numbers of enrollees in state Medicaid programs have resulted in the increased use of commercial managed care organizations by the states. Research shows that the implementation of these programs has produced mixed results. While many states have implemented managed care principles and have seen reductions in costs, some basic managed care tenets may not apply to a Medicaid population because of limited financial risk and responsibility. The application of commercial managed care organizations to these populations may not result in additional savings for those states already actively engaged in managed care. As such, the purpose of this article is to provide a synopsis of key managed care principles as applied to state Medicaid programs and discuss issues regarding the optimization of cost, access, and quality for this population.


Assuntos
Planos de Pagamento por Serviço Prestado/economia , Medicaid/economia , Planos Governamentais de Saúde/economia , Custos e Análise de Custo/economia , Acessibilidade aos Serviços de Saúde/economia , Humanos , Programas de Assistência Gerenciada/economia , Estados Unidos
17.
J Manag Care Spec Pharm ; 22(4): 347-56, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27023688

RESUMO

BACKGROUND: The development of abuse-deterrent opioid prescription medications is a priority at the national level. Pharmaceutical manufacturers have begun marketing new formulations of currently available opioids that meet higher abuse resistance standards. Little information is available regarding the impact of these formulations on overall health care expenditures. OBJECTIVES: To (a) examine the relationship between health care expenditures and use of brand abuse-deterrent or tamper-resistant (ADTR) extended-release opioids versus standard dosage form (SDF) extended-release opioids in a state Medicaid population, and (b) determine whether this relationship was influenced by member-specific characteristics. METHODS: The study is a cross-sectional review of Oklahoma Medicaid members (aged ≥ 21 years) with at least 1 paid pharmacy claim for long-acting opioids between September 2013 and August 2014. Members who were adherent to extended-release opioid products were classified into ADTR and SDF opioid groups. The relationship between health care expenditures (prescription, medical, and overall) and opioid groups was examined using multiple linear regression models. The impact of member-specific characteristics (age, sex, race, urban classifications, and various comorbidities) on this relationship was examined. RESULTS: Prescription spending ($9,265,554) accounted for 35% of overall health care expenditures ($26,304,693) among 938 members during the 12-month reference period. Total prescription expenditures were higher among ADTR than SDF user groups, and the difference in median expenditures between these 2 groups was larger among members with more comorbidities, as measured by the Charlson Comorbidity Index score. Overall, ADTR users had higher median total health care and medical expenditures, and the difference in median expenditures was dependent on whether a member had comorbidities of addiction or not (higher expenditures were observed among members with comorbidities of addiction). CONCLUSIONS: The abuse and misuse of medically prescribed opioid products is a growing health epidemic. A variety of attempts have been made to reduce the potential of abuse and misuse of these products, including changes to product formulations. The results of this study indicate that both prescription spending and physician and pharmacy spending combined may be increased with the use of these new products because of higher pricing. Study findings also suggest that the use of ADTR opioids among members with comorbidities of addiction may be related to slightly lower overall health care and medical expenditures than those among members without comorbidities of addiction. Further research is required to answer questions regarding the comparative effectiveness of existing opioid prescription formulations. DISCLOSURES: No outside funding supported this research. Nesser is employed by the Oklahoma Health Care Authority, and Keast is a contractual employee for the Oklahoma Health Care Authority. The authors declare no other conflicts of interest. Study design was primarily contributed by Keast, along with Nesser and Farmer. Keast took the lead in data collection, while data interpretation was primarily performed by Owora, along with Keast and assisted by Nesser and Farmer. The manuscript was written and revised by all authors equally.


Assuntos
Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Uso Indevido de Medicamentos sob Prescrição/prevenção & controle , Adulto , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/economia , Química Farmacêutica , Comorbidade , Estudos Transversais , Preparações de Ação Retardada , Indústria Farmacêutica/economia , Feminino , Gastos em Saúde , Humanos , Modelos Lineares , Masculino , Medicaid/economia , Pessoa de Meia-Idade , Oklahoma , Estudos Retrospectivos , Estados Unidos
18.
J Ment Health ; 25(6): 486-491, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26485091

RESUMO

BACKGROUND: Several atypical antipsychotics (AAPs) are used as second-line agents for treatment resistant depression. AAPs can be expensive compared to other treatment options and can cause several side effects. OBJECTIVES: To estimate healthcare costs and utilization of AAPs compared to other second-line agents. METHODS: Observational study using Medicaid claims data (2006-2011). Subjects were depression-diagnosed adult members with at least two prescriptions of antidepressant medications followed by a second-line agent. Gamma generalized linear models (GLM) produced estimates of the difference in mean expenditures among treatment groups after adjusting for individual baseline characteristics using propensity scores. Negative binomial models produced estimates of the difference in number of hospitalizations and emergency department (ED) visits. RESULTS: A total of 3910 members received second-line treatment. Treatment groups were AAPs (n = 2211), augmentation agents other than AAPs (n = 1008), and antidepressant switching (n = 691). AAPs resulted in higher mean adjusted pharmacy costs and higher mean adjusted total mental health-related costs. Mean adjusted total healthcare costs and number of inpatient and ED visits were not different among treatments. CONCLUSION: The results show no evidence that AAPs used as second-line treatment for depression results in overall cost savings or lower inpatient and ED visits compared to other treatment strategies.


Assuntos
Antipsicóticos/economia , Transtorno Depressivo/economia , Gastos em Saúde , Adulto , Redução de Custos , Transtorno Depressivo/tratamento farmacológico , Quimioterapia Combinada/economia , Feminino , Humanos , Masculino , Medicaid , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
19.
Res Social Adm Pharm ; 12(1): 154-163, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-25980583

RESUMO

U.S. State Medicaid programs for the medically indigent strive to deliver quality health care services with limited budgets. An often used cost management strategy is prior authorization of services or prescription medications. The goal of this strategy is to shape the pharmaceutical market share in the most efficient manner for the particular state Medicaid program, much like commercial managed care organizations. These policies are often scrutinized due to the population Medicaid serves, which in the past was largely composed of individuals with vulnerable health status. Unintended consequences can occur if these policies are not carried out in an appropriate manner or if they greatly restrict services. The data used for policy implementation research is prone to certain problems such as skewness and multimodality. Previous guidelines have been published regarding the best practices when analyzing these data. These guidelines were used to review the current body of literature regarding prior authorization in Medicaid. Further discussed are additional characteristics such as therapeutic areas researched and the outcomes identified. Finally, the importance of considering state-specific characteristics when reviewing individual policies and the usefulness of these results for other programs are also considered.


Assuntos
Medicaid/estatística & dados numéricos , Projetos de Pesquisa , Interpretação Estatística de Dados , Guias como Assunto , Política de Saúde , Humanos , Farmácia , Mecanismo de Reembolso , Estados Unidos
20.
Am J Drug Alcohol Abuse ; 41(1): 1-6, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25490606

RESUMO

Society in America, like many others, continues to wrestle with the problem of misuse and abuse of prescription opioids. The implications of this struggle are widespread and involve many individuals and institutions including healthcare policymakers. State Medicaid pharmacy programs, in particular, undergo significant scrutiny of their programs to curtail this problem. While recent efforts have been made by government agencies to both quantify and offer methods for curbing this issue, it still falls to each state's policymakers to protect its resources and the population it serves from the consequences of misuse and abuse. This paper details the history of one state Medicaid's management of this issue at the pharmacy benefit level. Examples of various methods employed and the results are outlined and commentary is provided for each method. Regardless of the methods used to address this issue, the problem must still be a priority at all levels, not just for payers.


Assuntos
Analgésicos Opioides/provisão & distribuição , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Serviços Comunitários de Farmácia/legislação & jurisprudência , Prescrições de Medicamentos , Controle de Medicamentos e Entorpecentes , Política de Saúde , Humanos , Legislação de Medicamentos , Medicaid , Detecção do Abuso de Substâncias , Estados Unidos
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