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February 9, 1990, Vol 263, No. 6 >
ARTICLE | February 9, 1990

Withdrawing Payment for Nonscientific Drug Therapy: Title and subTitle BreakIntended and Unexpected Effects of a Large-Scale Natural Experiment FREE

Stephen B. Soumerai, ScD; Dennis Ross-Degnan, ScD; Steven Gortmaker, PhD; Jerry Avorn, MD
[+] Author Affiliations

Reprint requests to Department of Social Medicine, Harvard Medical School, 643 Huntington Ave, Boston, MA 02115 (Dr Soumerai).


JAMA. 1990;263(6):831-839. doi:10.1001/jama.1990.03440060077036
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Article
References

Little is known about the effect on clinical decision making of nonreimbursement for ineffective medical technologies. Using a time-series design, we studied the effects of cessation of government payment for 12 categories of drugs of questionable efficacy (Drug Efficacy Study Implementation drugs) in a random sample of the New Jersey Medicaid population (N = 390 465) and in four cohorts of regular users of these products. We measured changes in the overall levels of prescriptions, expenditures, and physicians' use of substitute drugs. Although withdrawn drugs accounted for 7% of prescriptions in the base year, there was no measurable reduction in overall drug use or expenditures after the regulation; prescription rates actually rose from 0.86 to 1.00 monthly prescriptions per enrollee throughout the 42-month study. Controlling for preexisting trends, an estimated drop in the use of study drugs of 21.7 prescriptions per 1000 enrollees per month was offset by an increase in the use of substitute drugs of 33.7 prescriptions. Both desirable and unimproved therapeutic substitutions were observed. Used alone, curtailment of reimbursement for marginally effective therapies results in both desirable and unintended clinical substitutions and may not reduce costs. Supplementing such restrictions with education may be necessary to promote practices that are more therapeutically and economically appropriate.

(JAMA. 1990;263:831-839)

REFERENCES

1 +
Lurie N, Ward NB, Shapiro MF, Brook RH.  Termination from Medi-Cal: does it affect health ? N Engl J Med. 1984;;311:480-484.
2 +
Soumerai SB, Avorn J, Ross-Degnan D, Gortmaker S.  Payment restrictions for prescription drugs under Medicaid: effects on therapy, cost, and equity . N Engl J Med. 1987;;317:550-556.
3 +
Holahan JF, Cohen JW. Medicaid: The Tradeoff Between Cost-Containment and Access to Care . Washington, DC: The Urban Institute Press; 1986;.
4 +
Smith T.  Limited lists of drugs: lessons from abroad . Br Med J. 1985;;290:532-534.
5 +
WHO Expert Committee. The Use of Essential Drugs . Geneva, Switzerland: World Health Organization; 1985;.
6 +
Eisenberg JM. Doctors' Decisions and the Cost of Medical Care. Ann Arbor, Mich: Health Administration Press; 1986;:129-131.
7 +
Cypress BK. Drug Utilization in General and Family Practice by Characteristics of Physicians and Office Visits: National Ambulatory Medical Care Survey, 1980 . Hyattsville, Md: National Center for Health Statistics; 1983;;87.
8 +
US Pharmaceutical Industry, 1986-1987: Annual Survey Report . Washington, DC: Pharmaceutical Manufacturers Association; 1988;.
9 +
Soumerai SB, Avorn J.  Efficacy and cost-containment in hospital pharmacotherapy: state of the art and future directions . Milbank Mem Fund Q. 1984;;62:447-474.
10 +
Steel K, Gertman PM, Crescenzi C, Anderson J.  Iatrogenic illness on a general medical service at a university hospital . N Engl J Med. 1981;;304:638-42.
11 +
Silverman M, Lee PR. Pills, Profits, and Politics . Berkeley: University of California Press; 1974;:107-137.
12 +
National Research Council. Drug Efficacy Study: A Report to the Commissioner of Food and Drugs . Washington, DC: National Technical Information Service; 1969;.
13 +
Hecht A.  A long reach back to assure drug quality . FDA Consumer. 1984;;18:15.
14 +
Smith DM, McKercher PL.  The elimination of selected drug products from the Michigan Medicaid formulary: a case study . Hosp Formulary. 1984;;19: 366-372.
15 +
Smith MC, Maclayton DW.  The effect of closing a Medicaid formulary on the prescription of analgesic drugs . Hosp Formulary. 1977;;12:36-41.
16 +
Ferrando C, Henman MC, Corrigan OL.  Impact of a nationwide limited prescribing list: preliminary findings . Drug Intell Clin Pharm. 1987;;21: 653-658.
17 +
Cook TD, Campbell DT. Quasi-Experimentation: Design and Analysis Issues for Field Settings . Boston, Mass: Houghton Mifflin Co; 1979;.
18 +
Federspiel CF, Ray WA, Schaffner W.  Medicaid records as a valid data source: the Tennessee experience . Med Care. 1976;;14:166-172.
19 +
Avorn J, Soumerai SB.  Improving drug-therapy decisions through educational outreach: a randomized controlled trial of academically-based 'detailing.' N Engl J Med. 1983;;308:1457-1463.
20 +
Schaffner W, Ray WA, Federspiel CF, Miller WO.  Improving antibiotic prescribing in office practice: a controlled trial of three educational methods . JAMA. 1983;;250:1728-1732.
21 +
Soumerai SB, Avorn J.  Economic and policy analysis of university-based drug 'detailing.' Med Care. 1986;;24:313-331.
22 +
National Technical Information Service. Medicaid Data as a Source for Postmarketing Surveillance Information , Vol. I: Technical Report. Research Triangle Park, NC: Research Triangle Institute; 1984;.
23 +
Ray WA, Griffin MR, Schaffner W, Baugh DK, Melton LJ III.  Psychotropic drug use and the risk of hip fracture . N Engl J Med. 1987;;316:363-369.
24 +
Drug Evaluations. 6th ed. Chicago, Ill: American Medical Association; 1986;.
25 +
American Hospital Formulary Service. Drug Information 86 . Bethesda, Md: American Society of Hospital Pharmacists; 1986;.
26 +
Drug Facts & Comparisons . St Louis, Mo: JB Lippincott; 1983;.
27 +
Ainley W, ed. Martindale, William The Extrapharmacopeia: Incorporating Squires Companion . 27th ed. London, England: Pharmaceutical Press; 1977;.
28 +
SAS User's Guide: Statistics. 1982 ed. Cary, NC: SAS Institute; 1982;.
29 +
Rao P, Miller RL, eds. Applied Econometrics . Belmont, Calif: Wadsworth Publishing Co; 1971;.
30 +
Gortmaker SL, Clark CJG, Graven SN, Sobol AM, Geronimus A.  Reducing infant mortality in rural America: evaluation of the Rural Infant Care Program . Health Serv Res. 1987;;22:91-115.
31 +
Gillings D, Makuc D, Siegel E.  Analysis of interrupted time series mortality trends: an example to evaluate regionalized perinatal care . Am J Public Health. 1981;;71:38-48.
32 +
Jang R.  Medicaid formularies: a critical review of the literature . J Pharmaceutical Marketing & Management . 1988;;2:39-61.
33 +
Lohr KN, Brook RH, Kamberg CJ, et al.  Use of medical care in the RAND Health Insurance Experiment: Diagnosis- and service-specific analyses in a randomized controlled trial . Med Care. 1986;;24( (suppl) ):S1-S87.
34 +
Hefner DL. Cost-effectiveness of a Restrictive Drug Formulary: Louisiana vs Texas . Washington, DC: National Pharmaceutical Council; 1980;.
35 +
Hammel RW.  Insights into public assistance medical care expenditures . JAMA. 1972;;219:1740-1744.
36 +
Melmon KL.  Preventable drug reactions: causes and cures . N Engl J Med. 1971;;284:1361-1368.
37 +
Spiro HM. Doctors, Patients and Placebos . New Haven, Conn: Yale University Press; 1986;.
38 +
Schwartz RK, Soumerai SB, Avorn J.  Physician motivations for nonscientific drug prescribing . Soc Sci Med. 1989;;28:577-582.
39 +
Marsh GN.  'Curing' minor illness in general practice . Br Med J. 1977;;2:1267-1269.
40 +
Woodward RS, Medoff G, Smith MD, Gray JL III.  Antibiotic cost savings from formulary restrictions and physician monitoring in a medical-school—affiliated hospital . Am J Med. 1987;;83:817-823.
41 +
Avorn J, Soumerai SB, Taylor W, Wessels MR, Janousek J, Weiner M.  Reduction of incorrect antibiotic dosing through a structured educational order form . Arch Intern Med. 1988;;148:1720-1724.
42 +
Buchwald D, Soumerai SB, Vandevanter N, Wessels MR, Avorn J.  Implementation of a hospital-wide reduction in clindamycin dosage scheduled: effects on clinical outcomes . Rev Infect Dis. 1989;;11:619-624.
43 +
Tartter PI, Barron DM.  Unnecessary blood transfusion in elective colorectal cancer surgery . Transfusion. 1985;;25:113-115.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Lurie N, Ward NB, Shapiro MF, Brook RH.  Termination from Medi-Cal: does it affect health ? N Engl J Med. 1984;;311:480-484.
2 +
Soumerai SB, Avorn J, Ross-Degnan D, Gortmaker S.  Payment restrictions for prescription drugs under Medicaid: effects on therapy, cost, and equity . N Engl J Med. 1987;;317:550-556.
3 +
Holahan JF, Cohen JW. Medicaid: The Tradeoff Between Cost-Containment and Access to Care . Washington, DC: The Urban Institute Press; 1986;.
4 +
Smith T.  Limited lists of drugs: lessons from abroad . Br Med J. 1985;;290:532-534.
5 +
WHO Expert Committee. The Use of Essential Drugs . Geneva, Switzerland: World Health Organization; 1985;.
6 +
Eisenberg JM. Doctors' Decisions and the Cost of Medical Care. Ann Arbor, Mich: Health Administration Press; 1986;:129-131.
7 +
Cypress BK. Drug Utilization in General and Family Practice by Characteristics of Physicians and Office Visits: National Ambulatory Medical Care Survey, 1980 . Hyattsville, Md: National Center for Health Statistics; 1983;;87.
8 +
US Pharmaceutical Industry, 1986-1987: Annual Survey Report . Washington, DC: Pharmaceutical Manufacturers Association; 1988;.
9 +
Soumerai SB, Avorn J.  Efficacy and cost-containment in hospital pharmacotherapy: state of the art and future directions . Milbank Mem Fund Q. 1984;;62:447-474.
10 +
Steel K, Gertman PM, Crescenzi C, Anderson J.  Iatrogenic illness on a general medical service at a university hospital . N Engl J Med. 1981;;304:638-42.
11 +
Silverman M, Lee PR. Pills, Profits, and Politics . Berkeley: University of California Press; 1974;:107-137.
12 +
National Research Council. Drug Efficacy Study: A Report to the Commissioner of Food and Drugs . Washington, DC: National Technical Information Service; 1969;.
13 +
Hecht A.  A long reach back to assure drug quality . FDA Consumer. 1984;;18:15.
14 +
Smith DM, McKercher PL.  The elimination of selected drug products from the Michigan Medicaid formulary: a case study . Hosp Formulary. 1984;;19: 366-372.
15 +
Smith MC, Maclayton DW.  The effect of closing a Medicaid formulary on the prescription of analgesic drugs . Hosp Formulary. 1977;;12:36-41.
16 +
Ferrando C, Henman MC, Corrigan OL.  Impact of a nationwide limited prescribing list: preliminary findings . Drug Intell Clin Pharm. 1987;;21: 653-658.
17 +
Cook TD, Campbell DT. Quasi-Experimentation: Design and Analysis Issues for Field Settings . Boston, Mass: Houghton Mifflin Co; 1979;.
18 +
Federspiel CF, Ray WA, Schaffner W.  Medicaid records as a valid data source: the Tennessee experience . Med Care. 1976;;14:166-172.
19 +
Avorn J, Soumerai SB.  Improving drug-therapy decisions through educational outreach: a randomized controlled trial of academically-based 'detailing.' N Engl J Med. 1983;;308:1457-1463.
20 +
Schaffner W, Ray WA, Federspiel CF, Miller WO.  Improving antibiotic prescribing in office practice: a controlled trial of three educational methods . JAMA. 1983;;250:1728-1732.
21 +
Soumerai SB, Avorn J.  Economic and policy analysis of university-based drug 'detailing.' Med Care. 1986;;24:313-331.
22 +
National Technical Information Service. Medicaid Data as a Source for Postmarketing Surveillance Information , Vol. I: Technical Report. Research Triangle Park, NC: Research Triangle Institute; 1984;.
23 +
Ray WA, Griffin MR, Schaffner W, Baugh DK, Melton LJ III.  Psychotropic drug use and the risk of hip fracture . N Engl J Med. 1987;;316:363-369.
24 +
Drug Evaluations. 6th ed. Chicago, Ill: American Medical Association; 1986;.
25 +
American Hospital Formulary Service. Drug Information 86 . Bethesda, Md: American Society of Hospital Pharmacists; 1986;.
26 +
Drug Facts & Comparisons . St Louis, Mo: JB Lippincott; 1983;.
27 +
Ainley W, ed. Martindale, William The Extrapharmacopeia: Incorporating Squires Companion . 27th ed. London, England: Pharmaceutical Press; 1977;.
28 +
SAS User's Guide: Statistics. 1982 ed. Cary, NC: SAS Institute; 1982;.
29 +
Rao P, Miller RL, eds. Applied Econometrics . Belmont, Calif: Wadsworth Publishing Co; 1971;.
30 +
Gortmaker SL, Clark CJG, Graven SN, Sobol AM, Geronimus A.  Reducing infant mortality in rural America: evaluation of the Rural Infant Care Program . Health Serv Res. 1987;;22:91-115.
31 +
Gillings D, Makuc D, Siegel E.  Analysis of interrupted time series mortality trends: an example to evaluate regionalized perinatal care . Am J Public Health. 1981;;71:38-48.
32 +
Jang R.  Medicaid formularies: a critical review of the literature . J Pharmaceutical Marketing & Management . 1988;;2:39-61.
33 +
Lohr KN, Brook RH, Kamberg CJ, et al.  Use of medical care in the RAND Health Insurance Experiment: Diagnosis- and service-specific analyses in a randomized controlled trial . Med Care. 1986;;24( (suppl) ):S1-S87.
34 +
Hefner DL. Cost-effectiveness of a Restrictive Drug Formulary: Louisiana vs Texas . Washington, DC: National Pharmaceutical Council; 1980;.
35 +
Hammel RW.  Insights into public assistance medical care expenditures . JAMA. 1972;;219:1740-1744.
36 +
Melmon KL.  Preventable drug reactions: causes and cures . N Engl J Med. 1971;;284:1361-1368.
37 +
Spiro HM. Doctors, Patients and Placebos . New Haven, Conn: Yale University Press; 1986;.
38 +
Schwartz RK, Soumerai SB, Avorn J.  Physician motivations for nonscientific drug prescribing . Soc Sci Med. 1989;;28:577-582.
39 +
Marsh GN.  'Curing' minor illness in general practice . Br Med J. 1977;;2:1267-1269.
40 +
Woodward RS, Medoff G, Smith MD, Gray JL III.  Antibiotic cost savings from formulary restrictions and physician monitoring in a medical-school—affiliated hospital . Am J Med. 1987;;83:817-823.
41 +
Avorn J, Soumerai SB, Taylor W, Wessels MR, Janousek J, Weiner M.  Reduction of incorrect antibiotic dosing through a structured educational order form . Arch Intern Med. 1988;;148:1720-1724.
42 +
Buchwald D, Soumerai SB, Vandevanter N, Wessels MR, Avorn J.  Implementation of a hospital-wide reduction in clindamycin dosage scheduled: effects on clinical outcomes . Rev Infect Dis. 1989;;11:619-624.
43 +
Tartter PI, Barron DM.  Unnecessary blood transfusion in elective colorectal cancer surgery . Transfusion. 1985;;25:113-115.

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