SCIENTIFIC
Examining the Impact of a Prior Authorization Program on Rural Child and Adolescent Psychiatry Patients and Families
AUTHORS : Jennifer M . Ludrosky , PhD 1
Bridget Skidmore , MD 1 Tanner J . Quiggle , MD 2 Lauren Swager , MD 1
1
Department of Behavioral Medicine and Psychiatry , West Virginia University School of Medicine
2
Department of Pediatrics , West Virginia University School of Medicine
INTRODUCTION
Prior authorization ( PA ) programs for medications are a common strategy guiding appropriate benefit usage , 1 including requiring physicians to obtain approval before prescribing nonpreferred , and typically more expensive , medications . These programs are largely successful in reducing drug-related costs for insurance providers and in addressing concerns about over or inappropriate prescribing . 1-6 However , many studies have noted concerns about the unintended consequences of PA programs on healthcare utilization , increased long-term healthcare costs , worsening disease status , reduced quality of care , and increased burden on the patient , provider , and pharmacy . 3 , 7-10 Furthermore , psychotropic medications specifically , including antipsychotic medications and stimulants , are often more frequently targeted by PA programs because of concerns about serious side effects , off-label usage , risk of abuse , and systemic inequalities . While the concerns about inappropriate prescription and fiscal responsibility are important considerations , sweeping policy change can also place unnecessary barriers on patients for whom the prescription of these medications are appropriate , necessary , and valid . Past studies show that PA programs for psychotropic medications can impact prescriber behavior and influence healthcare expenditures and outcomes . 1-3 These burdens are particularly impactful for rural patients , who
ABSTRACT
INTRODUCTION The objective of this study was to examine the impact of the prior authorization ( PA ) process from the perspective of rural child and adolescent psychiatry patients ’ families .
METHODS All patient families who visited an outpatient behavioral health clinic in rural Appalachia for psychiatry services between July and October 2018 were eligible for the study . Caregivers of children who were prescribed medications eligible for PA or who reported problems with PA were offered a paper survey to complete anonymously and return to a drop box after the visit .
RESULTS In total , 37 respondents reported 55 different psychiatric medications affected , primarily stimulants ( n = 22 ). Just over 75 % ( n = 28 ) of respondents reported delays in receiving their medication . Delays ranged anywhere from less
already experience significant barriers to psychiatric care , especially children . 11 Little is known about patient and family experiences with PA programs , particularly for children . Child and adolescent psychiatrists have advocated for including the perspectives of the patients and their families in assessing outcomes of PA programs in order to obtain a more holistic view of their impact . 12 We are unaware of any systematic attempt to assess the impact of PA programs on the burden and consequences of PAs on children and families for psychiatric medications .
METHODS
Participants included parents or caregivers attending a scheduled , outpatient psychiatric visit for their child at the outpatient behavioral health facility of a large hospital system in rural Appalachia . The payor mix of the clinic is approximately 50 % private and 50 % public payors . The vast majority of prior authorizations required for the clinic population ( 90 %) are than a day to more than a month . During those delays , respondents reported their children experienced many different adverse events when they were not receiving their medication . Commonly reported consequences of the delays included behavioral and emotional issues at home and at school , physical side effects from drug withdrawal , and increased aggression . Respondents also reported an increase in financial burden . In some cases , the educational opportunities available to the child were also restricted .
CONCLUSION Rural families face limited access to psychiatric care and significant unmet needs . This study documents additional burden for rural families related to the PA process , including financial , behavioral , emotional , and educational consequences . This preliminary data indicates a need for further study and highlights the necessity of considering potential burdens for families when creating PA policies .
from Medicaid payors . A cross-sectional survey was conducted with a convenience sample of parents or caregivers who presented for a child psychiatry appointment where the child was prescribed a medication that was impacted by the PA process . Participants had a scheduled follow-up appointment between July and October 2018 with child psychiatry services . If caregivers expressed problems with PAs during a visit or were prescribed medications known to require prior authorization , they were offered a paper survey to complete anonymously and return to a drop box in the waiting area after the visit .
The survey was developed by study clinicians based on prior clinical experience with the impact of delays or changes in medication due to the PA process . The survey was anonymous ; no identifying data was collected . Patients could choose to provide contact information on a separate page if they were interested in participating in a follow-up study . The question-
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