Policy restrictions for certain medications lead to decreased drug use and substantial savings for insurers

Policies that restrict reimbursement for certain medications can save money for health insurers without driving patients to seek other kinds of health care, a new review of studies suggests.

The most common restriction among the studies, which took place in the United States, Canada, Norway and Denmark, was the prior authorization policy. Usually, prior authorization plans require extra paperwork by doctors or patients to explain the need for a particular restricted drug.

In some cases, restricted reimbursement for gastric-acid suppressants, such as the brand Nexium, and non-steroidal anti-inflammatory medicines, such as the brand Celebrex, led to "decreased drug use and substantial savings on drugs" almost immediately, said Carolyn J. Green, Ph.D., of the University of Victoria in Canada, and colleagues.

Patients in these plans did not use more health services after the policies went into effect, which could mean that they did not suffer any further health problems because of the restrictions. However, similar policies for antipsychotic drugs, such as the brand Risperdal, did increase the use of health services without reducing overall costs, the researchers report.

Only two of the 29 studies in the analysis directly looked at individual health outcomes "and these were unable to conclude whether the policies had either a positive or negative effect on the patients' health," Green said. "Therefore, we are stressing the importance of developing restrictions aligned with comparative clinical research."

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

Third-party insurers such as Medicare and Medicaid in the United States hope to curb rising drug costs, since "spending more on medication could mean less money for hospitals, doctors and even other public services such as education and infrastructure," Green explained.

Policymakers would also like to encourage better medication use by adjusting reimbursement restrictions, she said. In the Cochrane studies, the researchers discovered, more patients used high blood pressure and cholesterol control medicines appropriately after reimbursement restrictions on those drugs were relaxed.

The relaxed restriction "provides a safety valve" that allows doctors to keep a wide range of therapeutic options while discouraging the use of high cost medicines that are often misused or overused, Green said.

"Medications targeted for reduction in use are often newer, expensive drugs with cheaper, effective alternatives," she said.

Still, patients who might be faced with a drug change because of these policies should ask their doctors and pharmacists whether "these equivalents are really equivalent" for their particular condition, said John O'Brien, Pharm.D., formerly with the College of Notre Dame of Maryland.

"If whatever you're taking is working, and someone wants to change it," he said, "the first question you should ask is, 'why?'"

Although the policies do appear to save money in several studies, the Cochrane researchers say that there should be more studies measuring the direct health influence of these policies, especially in cases where there are no clear alternatives to the restricted drugs.

Green also notes that the restrictions could be a burden for some patients, if the patients have difficulties "accessing or understanding information" about how the restrictions could affect their care.