Revealed Opportunism: How Physicians "Game" Prior Authorization Protocols Until They Are Rescinded

Area of Science:

• Pharmacoeconomics
• Health Services Research
• Clinical Pharmacology

Background:

• Prior authorization (PA) is a drug utilization management strategy.
• PA may incentivize physicians to falsify adverse event documentation to meet drug approval criteria.
• This practice can impact prescribing accuracy and patient care.

Purpose of the Study:

• To identify documentation patterns of physician gaming and underreporting behaviors related to ACE inhibitor prescribing.
• To evaluate the impact of PA requirements on adverse event documentation for more expensive drug approvals.
• Focus on primary care setting and specific drug classes (ACE inhibitors and ARBs).

Main Methods:

• Retrospective analysis of physician electronic reporting of adverse effects.
• Study period: 2004-2013 in an Israeli HMO.
• Compared ACE inhibitor adverse event rates before and after PA revocation for ARBs, stratifying patients by new vs. previously treated.

Main Results:

• 151,845 patients treated with ACE inhibitors were analyzed.
• Reported adverse events for newly treated patients peaked in 2007 and decreased after PA revocation for ARBs.
• Rates also decreased for previously treated patients after PA restraints were lifted.

Conclusions:

• PA requirements appear to influence physician reporting of drug side effects, potentially leading to inaccuracies.
• The observed decline in reported side effects post-PA revocation supports the hypothesis of physician incentivization.
• Physicians may document ACE inhibitor side effects to meet eligibility for ARB approval.