Medicaid Prior Authorization Policies Impact ADHD Treatments

Rachel Hulkower, JD, MSPH, Public Health Analyst, Cherokee Nation Assurance, Public Health Law Program, Office for State, Tribal, Local and Territorial Support

Rachel Hulkower, JD, MSPH

An examination of Medicaid prior authorization policies for medication treatment of attention-deficit/hyperactivity disorder (ADHD) finds policies are inconsistent across states, which could influence whether treatments are consistent with, or differ from recommended practices.

Rachel Hulkower, JD, MSPH, Public Health Analyst, Cherokee Nation Assurance, Public Health Law Program, Office for State, Tribal, Local and Territorial Support, Arlington, Virginia, and colleagues point out that ADHD treatment recommendations are not always followed.

"When best-practice recommendations are compared with indicators of clinical practice, it appears that current practices and best practices for pediatric ADHD treatment are misaligned," Hulkower and colleagues indicate.

They note that the American Academy of Pediatrics (AAP) recommends evidence-based parent and/or teacher-administered behavior therapy as first-line treatment for preschool-aged children, with medication reserved if behavior therapy fails to substantially improve the child's functioning and there is moderate to severe continued disturbance in the child's function. A combination of such therapy with medication is recommended for older children.

Some of the highest rates of ADHD diagnosis are among children with public health insurance, however, investigators suggest that states' Medicaid policies and prior authorization requirements could have a substantial impact of how this condition is treated.

"Some state Medicaid programs have implemented policies to try to manage the use of ADHD medications," explain the investigators. "These policies include prescription medication prior authorization policies and prescription drug lists that restrict coverage approvals to patients of a certain age or require additional provider involvement before payment is granted. These policies may guide physicians toward preferred pediatric ADHD treatments."

"The NCBDDD (National Center on Birth Defects and Developmental Disabilities) has identified Medicaid prior authorization policy interventions as a set of strategies that may control the use of ADHD medication among patients diagnosed with ADHD and may guide clinicians towards referral for behavior therapy," Hulkower said, elaborating in an interview reported in Public Health Law.

To characterize the states' Medicaid pediatric ADHD medication prior authorizations, the investigators conducted a cross-sectional mapping study of states' policies as of November 1, 2015. The data on policy characteristics and authorization criteria included data on age restrictions and fail-first behavior therapy requirements.

The investigators report, among their findings, that 27 state Medicaid programs have prior authorization policies for ADHD medications prescribed to children and adolescents, 16 of which were applicable only to children <6 years of age. In 2 states, Medicaid coverage is expressly denied for ADHD medication prescriptions for patients younger than specified age: Minnesota denies all ADHD medications for children <3 years; Texas denies immediate-release medications <3 years, and denies extended-release and non-stimulant formulations for children <6 years.

Twenty-five states have policies that list criteria for approval; with the most common approval criterion, found in 23 states, a documented ADHD diagnosis. Less common criteria include: ruling out other causes for symptoms; ADHD symptoms persisting for a specified duration; patient impairment demonstrated in social environments, and the administration of a psychological evaluation.

Several of the states' policy ask the prescriber to confirm that an alternative treatment has been considered, and 7 state policies ask whether non-medication treatments such as behavior therapy had been attempted before the requested medication coverage. One state, Florida, requires the prescriber demonstrate not only that non-medication treatments are considered, but that an adequate trial failed to improve a patient's symptoms.

Hulkower indicated that the database developed from this study, available to the public, will next be analyzed in conjunction with Medicaid claims data for diagnosis and treatment of ADHD with prescription medications and psychological services to ascertain effects on ADHD treatment patterns.

"Research has not yet examined how prior authorization policies impact receipt of the recommended first-line treatment for these families, which is behavior therapy," Hulkower told MD Magazine. "Evaluation of the impact of prior authorization policies on behavior therapy rates would document whether prior authorization policies are effectively supporting best practices for young children with ADHD."

The assessment of Medicaid prior authorization policies for medication treatment of ADHD was published in the November/December issue of Public Health Reports.

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