HCFA should encourage states to share info on Medicaid DUR systems -- GAO.

HCFA SHOULD HELP STATES SHARE INFO ON MEDICAID DUR SYSTEMS, GAO URGES in a June 11 report entitled "Prescription Drugs and Medicaid: Automated Review Systems Can Help Promote Safety, Save Money." The General Accounting Office report was requested by Reps. Clinger (R-Penn.), Shays (R-Conn.) and Towns (D-N.Y.). "At present, states have no systematic way to share experiences and best practices," GAO concluded.

GAO suggested the Health Care Financing Administration "quickly help establish a working group or other such forum for coordinating the collecting and sharing of information on best practices for automated prospective drug utilization review programs, on a nationwide basis."

Utilization review before Medicaid prescriptions are dispensed is mandated by law; 43 states and the District of Columbia have or plan to implement automated DUR systems. The law does not specify automated DUR. An August 1994 GAO report found benefits from automated systems ("The Pink Sheet" Aug. 15, 1994, T&G-5).

The current GAO report reviews 12 months of data from five states with automated prospective DUR systems in place: Maryland, Missouri, New Mexico, Oregon and Pennsylvania. The states "screened for different conditions and handled prescription cancellations differently," GAO noted.

During the study year, 6.3 mil. prescriptions generated alerts to pharmacists out of 31.7 mil. total Rx drug claims, for an alert rate of 20%, the report found. Alerts led to cancellation of 650,000 scripts (10% of alerts, or 2% of total Rxs). "These systems also reduced program costs by over $30 mil.," GAO calculated.

Rejections of early refills accounted for $5 mil. of the savings, GAO said. "The remaining $25 mil. resulted from prescriptions that were denied due to patient ineligibility." GAO suggested greater, although undocumented, savings were accrued through "avoided hospitalization due to inappropriate drug therapy." Installation costs for the DUR systems were estimated to be $1.8 mil. total for the five states.

Of the alerts generated by the automated DUR systems, overutilization warnings were the most common (1.6 mil. scripts), followed by therapeutic duplication (1.5 mil. scripts), drug-drug interaction (752,000 Rxs), underutilization (403,000 Rxs), drug-disease interaction (398,000) and pregnancy alerts (15,000), GAO found. Other warnings, including excessive daily dose, were generated for 1.7 mil. scripts. Only overutilization, therapeutic duplication and drug-drug interaction warnings were used by all five states.

"How alerts regarding early refill and therapeutic duplication claims are administered can affect savings," GAO wrote. The HHS Inspector General issued a report in May 1995 reviewing different state interventions, recommending "mid-range" interventions ("The Pink Sheet" June 19, 1995, p. 4). GAO pointed to the experience of two states, one requiring pharmacists to deny early refill claims and the other with automatic denial. The pharmacist denial state gained $153,000 from canceled claims, compared to $1.2 mil. for the automatic denial state, despite a lower number of claims (3.2 mil. v. 5.8 mil.) in the state with automatic denial, GAO reported.