Prior authorization policies in Medicaid programs: The importance of study design and analysis on findings and outcomes from research.


Journal Article

U.S. State Medicaid programs for the medically indigent strive to deliver quality health care services with limited budgets. An often used cost management strategy is prior authorization of services or prescription medications. The goal of this strategy is to shape the pharmaceutical market share in the most efficient manner for the particular state Medicaid program, much like commercial managed care organizations. These policies are often scrutinized due to the population Medicaid serves, which in the past was largely composed of individuals with vulnerable health status. Unintended consequences can occur if these policies are not carried out in an appropriate manner or if they greatly restrict services. The data used for policy implementation research is prone to certain problems such as skewness and multimodality. Previous guidelines have been published regarding the best practices when analyzing these data. These guidelines were used to review the current body of literature regarding prior authorization in Medicaid. Further discussed are additional characteristics such as therapeutic areas researched and the outcomes identified. Finally, the importance of considering state-specific characteristics when reviewing individual policies and the usefulness of these results for other programs are also considered.

Full Text

Cited Authors

  • Keast, SL; Farmer, K; Smith, M; Nesser, N; Harrison, D

Published Date

  • January 2016

Published In

Volume / Issue

  • 12 / 1

Start / End Page

  • 154 - 163

PubMed ID

  • 25980583

Pubmed Central ID

  • 25980583

Electronic International Standard Serial Number (EISSN)

  • 1934-8150

International Standard Serial Number (ISSN)

  • 1551-7411

Digital Object Identifier (DOI)

  • 10.1016/j.sapharm.2015.04.003


  • eng