Pharmacist and physician satisfaction and rates of switching to preferred medications associated with an instant prior authorization program for proton pump inhibitors in the North Carolina Medicaid program.

BACKGROUND: Proton pump inhibitors (PPIs) are among the highest expenditure drugs covered by health care plans. During fiscal year 2001-2002, Medicaid programs nationwide spent nearly $2 billion on PPIs. Although the costs of individual PPIs vary widely, there is little variation in therapeutic effectiveness. On June 1, 2007, the North Carolina Medicaid program implemented an "instant approval" option simultaneously with a prior authorization (PA) program for PPIs with the goal of managing costs and maintaining high-quality care. Preferred PPIs included generic omeprazole and Prilosec OTC. This instant approval process (IAP) was expected to impose less administrative burden than is typically associated with PA programs by permitting physician and nonphysician prescribers to either write the PA criteria directly on a prescription form or use "MD Easy," a preprinted form that could be faxed by the prescriber to the dispensing pharmacy. A previous study found that from the prescriber's perspective the IAP reduced practice-related administrative burden and was associated with a reduced gap in PPI therapy when compared with traditional PA. OBJECTIVE: To evaluate the acceptability and effectiveness of this IAP for PPIs as assessed by the outcome measures of (a) pharmacist satisfaction with the IAP; (b) physician and pharmacist satisfaction with the MD Easy form; and (c) utilization rates for preferred PPIs, comparing medical practices that used the MD Easy form with practices that did not. METHODS: A cross-sectional design was used to assess pharmacist and physician satisfaction. A stratified random sample of 240 pharmacies was selected from 1,561 North Carolina pharmacies with claims in the Medicaid claims data file during state fiscal year 2006. Additionally, a stratified random sample of 240 medical practices was selected from 1,045 primary care practices serving Medicaid beneficiaries during 2006. Surveys were administered to pharmacists using either in-person interviews or self-administered questionnaires and to physicians using a mailed questionnaire with follow-up to nonrespondents. An interrupted time series analysis was used to evaluate the effect of the MD Easy form on switching to preferred PPIs using paid Medicaid claims of surveyed practices from calendar year 2007. Practices that reported both using the IAP and receiving the MD Easy form were defined as MD Easy users. Monthly market share data were analyzed using log negative binomial regression models to account for autocorrelation in the time series data. RESULTS: The pharmacy survey was completed by 202 (84.2%) pharmacies selected for participation. Of 198 permanently employed pharmacists, 140 (70.7%) reported experience with the IAP for PPIs. More than two-thirds (68.6%) of the pharmacist respondents with IAP experience indicated that the IAP is better (34.3%) or much better (34.3%) than traditional PA with RESEARCH respect to overall administrative burden of phone calls, faxes, patient interactions, and doctor contacts. Surveys were completed by 171 (71.3%) of selected physician practices, of which 56 (32.7%) reported experience with the MD Easy forms. Of practices that recalled receiving the MD Easy forms, 52 of 56 (92.9%) reported that the forms "very much" or "somewhat" helped prevent gaps in PPI therapy; 54 of 55 (98.2%) reported that they helped identify patients affected by Medicaid PPI PA; and 100% reported that they helped physicians to follow PA requirements. Immediately after implementation of the IAP and MD Easy form, the observed market share of preferred PPIs increased by 4.1 times (95% CI = 3.57-4.62). From May to June 2007, the preferred PPI market share increased by 64.0 percentage points, from 19.3% to 83.3% (P < 0.001), for practices that reported using the IAP and receiving the MD Easy form (n = 56) and by 55.4 percentage points, from 21.8% to 77.2% (P < 0.001), for practices that either (a) reported not receiving the MD Easy form (n = 25) or (b) reported not using the IAP (n = 84) or (c) did not respond to the survey item asking about the MD Easy form (n = 4). The overall increase in preferred PPI market share after implementation of the IAP was 1.29 times higher for practices that used the MD Easy form than for those that did not based on negative binomial regression modeling; this difference approached statistical significance (95% CI = 1.00-1.68; P = 0.053). CONCLUSION: This study suggests that an IAP for PPIs using either handwritten prescriptions or a preprinted form is an effective alternative to traditional PA. The IAP was associated with an increase in market share for preferred PPIs and was perceived by pharmacists as less administratively burdensome than traditional PA. Additional studies are needed to determine sustainability and the applicability to other prescription drugs.

Estimated savings from paid telephone consultations between subspecialists and primary care physicians.

OBJECTIVES: Pediatric subspecialists are not routinely reimbursed by Medicaid or insurance payers for telephone consultations. Generally, access to pediatric subspecialists is limited because of the small number of providers, their concentration in academic medical centers, and increasing demand for their services. Little is known about the nature of such consults, the time required to provide them, or whether there is a positive economic impact for payers. METHODS: Between March and October of 2007, pediatric subspecialists from 6 academic medical centers in North Carolina completed consultation reimbursement-request forms to prospectively track their telephone consultations with primary care physicians for the care of Medicaid patients<22 years of age. Data collected included the amount of time required per consult and consult outcomes in terms of service use and quality of care. Medicaid claims records and primary care physician surveys were used to validate the pediatric subspecialist consultation outcomes. RESULTS: A total of 47 pediatric subspecialists provided 306 consults regarding the care of 292 Medicaid-insured children over the 8 study months. Telephone consults were generally <15 minutes in length and exceeded 30 minutes in <7% of calls. Pediatric subspecialists reported that telephone consults led to avoidance of specialist visits (n=98), hospital transfers (n=35), hospital admissions (n=14), and emergency department visits (n=14). Medicaid claims data supported these reports; matched primary care physician surveys suggested even higher levels of service avoidance. After adjusting for the reimbursed costs of providing telephone consults, an estimated $477274 was saved ($39 per dollar spent). CONCLUSIONS: Telephone consultations with pediatric subspecialists provide a valuable service to primary care physicians providing medical homes to Medicaid patients. Rewarding physicians for telephone consults seems to be cost-effective because of reduced use of costly services and reported improvements in quality of care.

A medical home for children with insulin-dependent diabetes: comanagement by primary and subspecialty physicians--convergence and divergence of opinions.

OBJECTIVE: The purpose of this work was to examine pediatricians' and endocrinologists' views about management for routine preventive and acute care, diabetes-specific care, and family education and care coordination for children with insulin-dependent diabetes. METHODS: We conducted a mixed-mode survey of all of the pediatricians in 1 medicaid managed care network and all of the pediatric and adult endocrinologists who treat children with diabetes in North Carolina. RESULTS: Of the 201 pediatricians surveyed, 132 responded (65%). Among the 61 endocrinologists who treat children, 59% replied. Nearly all of the respondents agreed that primary care physicians should have responsibility for routine primary care (eg, well-child checkups, treating minor illnesses or injuries, and immunizations). Likewise, large majorities favored endocrinologists as leads for diabetes-specific care (eg, 94% for training in use of an insulin pump and 82% for training in use of a glucometer). Many generalists and subspecialists reported that specific aspects of diabetes care should be comanaged (eg, 31% for tracking of hemoglobin A1c). However, large proportions of pediatricians and endocrinologists expressed differing opinions about the primary responsibility for family education and care coordination and for specific diabetes services. For example, 80% of endocrinologists saw subspecialists as leads for monitoring blood sugar levels, whereas 52% of pediatricians favored comanagement. CONCLUSIONS: An effective medical home model of care depends on establishing clear lines of responsibility between the primary care physician and subspecialist. Our findings suggest that primary care physicians and subspecialists agree on who should lead most aspects of care for patients with insulin-dependent diabetes and that some aspects of care should be comanaged. However, primary care physicians and subspecialists did not agree either between or within disciplines on who should be more responsible for the basic aspect of monitoring of blood sugar levels. Approaches that recognize the appropriate division of care between primary care physicians and subspecialists, facilitate comanagement when it is needed, and reward the collaboration required to provide medical homes for patients should be investigated as models of care.