Medicaid prior authorization policies for the medication treatment of attention-deficit/ hyper activity disorder (ADHD) vary by state. Because of these inconsistencies many people wonder whether treatments administered are consistent with the best 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, said, "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,”
What are the recommended treatments?
The American Academy of Pediatrics (AAP) recommends behavior therapy for pre-school aged children. If this fails, medication is recommended as a backup.
To limit the use of ADHD medications Medicaid programs have enforced prescription medication prior authorization policies and prescription drug lists. These policies are designed to push physicians to follow recommended treatments.
Investigators evaluated the Medicaid programs throughout different states to define these policies.
Here are their findings:
- 27 states Medicaid programs have prior authorization policies for ADHD medications prescribe to children and adolescents.
- 16 of these programs apply only to children 6 or younger.
- 2 deny ADHD medication prescriptions for patients younger than a specified age
- Minnesota denies ADHD medications for all children younger than 3.
- Texas denied immediate release of medication to children younger than 3 and extended-release and non-stimulant formulations for children younger than 6.
- 25 states have policies that list criterion for approval.
- The most common of these criterion is that there be a documented ADHD diagnosis
- Some of the lesser known criterion included: ruling out other causes for symptoms, ADHD symptoms persisting for a period of time, patient impairment demonstrated in a social environment, and the administration of a psychological evaluation.
- Some states require the prescriber to confirm that alternative treatment has been considered
- 7 ask that behavior therapy has been attempted before the use of medication.
- Florida requires the prescriber to demonstrate that non-medication treatments have been considered and that an adequate trial failed to improve the patient’s symptoms.
Hulkower alluded to the next step being an analysis of this data in conjunction with Medicaid claims. This will show whether Medicaid policies have been effective in influencing physicians to follow the best practices.