Prescription Drugs and Medicaid: Automated Review Systems Can Help Promote Safety, Save Money

Front Cover
DIANE Publishing, 1996 - 31 pages
Inappropriate use of prescription drugs can cause adverse reactions. States have established programs to review Medicaid prescriptions before drugs are dispensed to prevent these reactions. Most states have implemented automated prospective drug utilization (PRODUR) systems. This report examines states' experiences in using automated PRODUR systems & focuses on how such systems can improve patient safety by identifying & preventing inappropriate drug therapy, reduce program costs, & reduce the incidence of fraud, waste, & abuse.
 

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Page 1 - Honorable William F. Clinger, Jr. Chairman Committee on Government Reform and Oversight House of Representatives...
Page 31 - ... point-of-distribution review of drug therapy using predetermined standards before each prescription is filled or delivered to the recipient or the recipient's caregiver. The review must include screening to identify potential drug therapy problems of the following types: (1) Therapeutic duplication, that is, the prescribing and dispensing of two or more drugs from the same therapeutic class such that the combined daily dose puts the recipient at risk of an adverse medical result or incurs additional...
Page 11 - HCFA's Information Sharing Has Been Limited As stated earlier, the Social Security Act, as amended by the Omnibus Budget Reconciliation Act of...
Page 30 - Treatment standard recommendation for the condition for which it was prescribed. Over-utilization Use of a drug in quantities or for durations that put the recipient at risk of an adverse medical result. Pregnancy Conflict Use of the prescribed drug is not recommended during pregnancy. Therapeutic Duplication The prescribing and dispensing of two or more drugs from the same therapeutic class, such as analgesics (pain relievers), resulting in a combined daily dose that puts the recipient at risk of...
Page 18 - Mar. 31, 1997). Fraud and Abuse: Providers Excluded From Medicaid Continue to Participate in Federal Health Programs (GAO/T-HEHS-96-205, Sept. 5, 1996). Prescription Drugs and Medicaid: Automated Review Systems Can Help Promote Safety, Save Money (GAO/AIMD-96-72, June 11, 1996).
Page 19 - We agree that automated prospective drug utilization review (DUR) systems are extremely beneficial in ensuring that prescriptions are medically necessary and unlikely to cause adverse drug reactions.
Page 20 - PRODUR System Alerts and Cancellations, July 1, 1994 Through June 30, 1995 Total number of claims processed...
Page 20 - Alerts and Claim Cancellations Resulting From States' PRODUR Systems The following tables provide detailed contractor- and state-provided data on the results of automated PRODUR systems during 1994 and 1995. These data, which we did not independently verify, include (1) the number and cost of claims processed, (2) the types and numbers of drug therapy alert messages sent via the states...
Page 23 - Drug-disease interaction 40,451 Drug-drug interaction 223,665 Excessive daily dose 64,238 Excessive daily dose/children 694 Excessive daily dose/over age 65 19,744 Excessive quantity dispensed 5,439 Insufficient daily dose for age 11,765 Overutilization (early refill) 309,081 Pregnancy conflict 6,887 Therapeutic duplication 196,014 Underutilization 25,367 Total number of alerts 912,013 Total number of claims canceled due to alerts 23,810 Source: State data, which we did not independently verify...
Page 5 - PRODUR systems, hi addition, our estimates of cost savings derived from avoided hospitalization are based on FDA data. "Two of the states included in our earlier review (see GAO/AIMD-94-130, Aug. 5, 1994)— Tennessee and West Virginia — were not included in this review because of data-availability problems. Therefore, two other states — New Mexico and Oregon — were added to Maryland, Missouri, and Pennsylvania.

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