Oversight of antipsychotic use in Medicaid-insured children varies by state




Though 31 states now require prior authorization for prescribing atypical antipsychotic medications to Medicaid-insured youth, age limits and how the medications are regulated vary widely.

Requirements for physician peer review, an important consideration for a medication class with potentially negative cardiometabolic impact, also vary by state, Julie M. Zito, Ph.D., of the University of Maryland’s department of pharmaceutical health services research, and her associates reported in a research letter to JAMA (2015 March 3 [doi:10.1001/JAMA.2015.0763]) Dr. Zito and her colleagues noted that pediatric outpatient antipsychotic prescribing has sharply increased over the past 2 decades, and that a child on Medicaid is five times more likely to be prescribed an antipsychotic than a privately insured youth. Clear guidelines are lacking for antipsychotic prescribing, especially for the youngest patients, the study found.

Many states have instituted policies to gain greater oversight of pediatric psychotropic medication prescribing. To characterize nationwide practice, Dr. Zito and her colleagues collected information about prior authorization requirements for atypical antipsychotic prescribing for all 50 states and the District of Columbia. Information was collected by visiting webpages and supplemented by individual e-mail exchanges with state Medicaid authorities when necessary.

In all, 31 states’ Medicaid agencies had policies requiring prior authorization before atypical antipsychotics can be prescribed to Medicaid-insured children. Only seven states required prior authorization for all youth 18 and younger, while most others curtailed the requirement after ages 5, 6, or 7. A separate set of seven states had prior authorization requirements that varied by drug.

The prior authorization process also varied widely between states. Fifteen of the 31 states with prior authorization requirements had mandatory peer review by physicians – often psychiatrists – or had clinical pharmacists perform initial review with physicians available for consultation. By contrast, the other 16 states’ review processes were performed by nonphysician reviewers or were automated.

Dr. Zito and her colleagues said that the study compiled only limited data regarding each state’s policies. The authors recommended further study aimed at tracking unintended consequences of prescribing restrictions, as well as examining whether prior authorization with peer review improves quality of care. All in all, Dr. Zito said in an interview, “we need a much more comprehensive and holistic picture of this complex problem.”

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