Procedural Prescription Denials and Risk of Acute Care Utilization and Spending Among Medicaid Patients
Notice bibliographique
Résumé
Importance: Rising prescription medication costs under Medicaid have led to increased procedural prescription denials by health plans. The effect of unresolved denials on chronic condition exacerbation and subsequent acute care utilization remains unclear. Objective: To examine whether procedural prescription denials are associated with increased net spending through downstream acute care utilization among Medicaid patients not obtaining prescribed medication following a denial. Design, Setting, and Participants: This cross-sectional study used Medicaid claims data from 2022 to 2023 for patients at inpatient, outpatient, and pharmacy sites of care across 2 states (Virginia and Washington) and 2 independent health plans. Patients with at least 1 prescription denial in the study period (January 1 through July 31, 2023) were matched to those without denials in a given medication class, based on demographics, health plan data, chronic condition history, and health care utilization. Rates of and spending for physiologically related acute care visits in the 60 days following a medication fill or denial were compared for the study period. Main Outcomes and Measures: The main outcomes were all-cause acute care utilization and total medical spending (in 2023 US dollars per member per year [PMPY]) for principal diagnoses physiologically related to each medication class, in the 60 days following a medication fill or denial. Sensitivity analyses were performed to check for spurious associations or unmeasured confounders. Results: The 19 725 patients in this study had a median age of 41 (IQR, 29-55) years, and most (60.7%) were female. Patients had a mean (SD) of 3.3 (16.1) comorbidities, 1.0 (2.6) all-cause acute care visits, and 5.6 (7.8) primary care visits during the baseline period. Patients experiencing specific procedural prescription denials had a higher risk of physiologically related emergency department visits and hospitalizations compared with those without a denial in the subsequent 60 days (adjusted odds ratio, 1.40 [95% CI, 1.03-1.88] minimum vs 1.75 [95% CI, 1.39-2.20] maximum for exposure and control groups across the 7 medication classes with significant differences). Denials in 6 medication classes were associated with net total medical spending increases, ranging from $624 (95% CI, $435-$813) to $3016 (95% CI, $1483-$4550) in additional expense PMPY after accounting for both prescription and medical costs attributed to denials. Conclusions and Relevance: The findings of this cross-sectional study suggest that although procedural prescription denials aimed to curb immediate drug costs, some denials prompted heightened acute care utilization and costs that outweighed the short-term prescription budget savings. Health plans should incorporate this potential unintended consequence when shaping prescription coverage policies. Future research should systematically review all medication classes across plans nationally.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,000 | 0,000 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,000 | 0,000 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».