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MARYLAND MEDICAID PILOT H[2] BLOCKER PRESCRIBER INTERVENTION

Executive Summary

MARYLAND MEDICAID PILOT H[2] BLOCKER PRESCRIBER INTERVENTION study is the first step in a plan designed to establish an educational rather than administrative approach to influencing physician prescribing of Medicaid-covered drugs. The pilot study, which current plans call for holding to an educational approach to influencing prescribing patterns, is expected to begin in late summer or early autumn. If pursued in that format, the study may indicate a shift in Maryland's previously stated plan to control waste and costs under the Medicaid program. That plan would establish a formulary of preferred drugs, a state "advisory" (pharmacy and therapeutics) committee and prior authorization requirements in an approach that would feature therapeutic interchangeability of products within given drug classes ("The Pink Sheet" Jan. 21, p. 6). Both physician and pharmacist groups in Maryland reportedly prefer a strictly educational approach to influencing prescribing patterns. Physicians would rather not have to clear prescriptions with the state under a prior authorization program, and pharmacists are eager to avoid the need to question prescriptions with prescribers while patients wait in their stores. The overall study of the usefulness of prescriber intervention within a drug utilization review (DUR) program is being conducted by the University of Maryland under contract with the state. The pilot program will compare Medicaid prescriber and pharmacy databases from two locations within the state and measure the extent to which physician interventions influence prescribing patterns in one area as compared to a control area where there is no prescriber intervention. The pilot study will focus on appropriate prescribing of H[2] blockers in terms of criteria such as acute v. maintenance dosage levels and duration of therapy. As currently envisioned, the study will ignore the comparative costs to Medicaid of the various products -- Zantac, Tagamet, Axid and Pepcid. Under the pilot program, a pharmacist will visit any physician who, according to the Medicaid databases, has inappropriately prescribed an H[2] blocker. The university has drafted criteria for appropriate prescribing of H[2] blockers and must clear them with the state's medical society and pharmacists association. A second draft of the criteria was sent to the medical society for review the week of April 15. The university expects to expand the pilot study to other drug classes later in the fall. Pennsylvania's Department of Aging agreed at an April 18 meeting to establish a regulatory approach to correcting the misprescribing of psychotropic drugs under the state's PACE program. The Aging Department decided that reimbursement for prescription drugs under the Pharmaceutical Assistance Contract for the Elderly (PACE) program would be denied to beneficiaries for whom benzodiazepines or other psychotropic agents are overprescribed or misprescribed. In addition, the plan calls for a halt to patient reimbursement of physicians who demonstrate a pattern of overprescribing or misprescribing such products. Since September 1987, PACE has operated a therapeutic DUR program that features physician education and provides CME (continuing medical education) credits for physicians. It also features interventions by letter for physicians who misprescribe or overprescribe. Under the PACE system, prescriber, beneficiary and drug file databases are screened for all 400,000 beneficiaries on a monthly basis, and patient profiles for the 3,000 worst cases of possible prescription error in five drug classes are culled out. The classes are nonsteroidal anti-inflammatory drugs, H[2] blockers, calcium channel blockers/digoxin, psychotropics/antidepressants and benzodiazepines. Regional review committees throughout the state review the 3,000 patient profiles each month and intervention letters are sent to 50% of the prescribers involved. PACE will add the regulatory approach to the educational interventions because the Aging Department is said to be frustrated with the lack of response to the letters by a "significant few" prescribers. Over the last three years, the therapeutic DUR program has saved an estimated $ 250,000 per year for PACE, which has an annual budget of $ 250 mil. However, PACE considers the purpose of the intervention program to be optimal prescribing and drug therapy outcomes, not cost savings.
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