Access barriers for the low-income elderly: The impact of Medicaid prescription drug utilization management policies on medication nonadherence

While Medicaid was an important source of drug coverage for the low-income elderly prior to the Medicare drug benefit, it sought to contain costs through the use of policies designed to curb patient utilization. It has been postulated that these utilization management policies may directly impact drug nonadherence behaviors. This study examines the association of utilization management policies with drug access problems for the low-income elderly as measured by different indicators of nonadherence.; Using a cross-sectional design, this study analyzes 2003 national survey data to assess the overall impact of policy as well as the individual and interactive effects of six commonly used drug utilization management strategies (e.g. preferred drug lists, prior authorization, mandatory generic substitution, step-therapy, drug quantity limits, and cost-sharing) on access to medications for the low-income elderly who were dually insured through Medicare and Medicaid (i.e., "dual eligibles").; Preferred drug lists were significantly associated with failure to fill one or more medications due to cost (adjusted OR, 2.92; CI 1.75, 4.88) and skipping/taking smaller doses of medication to make last longer (adjusted OR, 1.87; CI 1.08, 3.25). Prior authorization was significantly associated with skipping/taking smaller doses of medication (adjusted OR, 1.64; CI 1.05, 2.57). Certain combinations of policies were found to be associated with reduced access. The odds of failing to fill, skipping, or taking smaller doses were nearly twice as high when both copayments and limits were in effect compared to when each policy was in place absent the other. The study did not find significant results for low-income seniors with health problems. Nor did this study detect a significant relationship between number of policies and nonadherence behaviors, suggesting that number of policies may be less important in predicting drug access problems than the type and combination of policies.; This research has important implications for Medicare which permits drug plans to use similar utilization management policies. Findings from this study alert policymakers to the potential risks to patient access posed by certain utilization management methods and suggest considerations to ensure that access to medications is not compromised as a result of these benefit design features.