Prescription Drugs and Medicaid:
Automated Review Systems Can Help Promote Safety, Save Money
AIMD-96-72: Published: Jun 11, 1996. Publicly Released: Jul 11, 1996.
Additional Materials:
- Full Report:
Contact:
(202) 512-6253
contact@gao.gov
Office of Public Affairs
(202) 512-4800
youngc1@gao.gov
Pursuant to a congressional request, GAO reviewed states' experiences with automated prospective drug utilization review (PRODUR) systems in their Medicaid programs, focusing on: (1) how these systems can improve patient safety, control program costs, and reduce fraud, waste, and abuse; and (2) impediments to effective implementation of PRODUR systems.
GAO found that: (1) between January 1994 and June 1995, PRODUR systems reviewed screened over 31.7 million prescription drug claims, and alerted pharmacists to potentially inappropriate drug treatments; (2) over 650,000 prescriptions were cancelled because of potential risks to patients; (3) PRODUR systems have reduced Medicaid costs by denying prescriptions to ineligible recipients, preventing hospitalizations due to illnesses caused by inappropriately prescribed drugs, and detecting and eliminating fraud and abuse; (4) PRODUR systems are more cost-effective than traditional review systems; (5) states implement their PRODUR systems differently because there is no guidance on PRODUR system implementation; and (6) each state has its own drug utilization review board which independently sets screening criteria and policies, but states have no systematic way to share experiences and best practices.
Recommendation for Executive Action
Status: Closed - Implemented
Comments: HCFA did not actively facilitate sharing information with the states on the most efficient use of PRODUR systems. However, GAO identified in a February 1997 follow-up survey, that the states received copies of the report and that this report was instrumental in many of these states implementing automated PRODUR systems. Moreover, several states told GAO they implemented some or all of the best practices identified in the report.
Recommendation: Given the substantial safety benefits that can accrue to Medicaid recipients and the strong potential for immediate savings to the Medicaid program through the effective use of automated PRODUR systems, the Secretary of Health and Human Services should direct the Administrator, Health Care Financing Administration, to actively facilitate state sharing of information on the most efficient use of PRODUR systems. One way would be to quickly help establish a working group or other such forum for coordinating the collecting and sharing of information on best practices for automated PRODUR programs, on a nationwide basis.
Agency Affected: Department of Health and Human Services
Explore the full database of GAO's Open Recommendations
»
Jan 14, 2021
-
Medicaid:
Data Completeness and Accuracy Have Improved, Though Not All Standards Have Been MetGAO-21-196: Published: Jan 14, 2021. Publicly Released: Jan 14, 2021.
Jan 4, 2021
-
Medicare Severe Wound Care:
Spending Declines May Reflect Site of Care Changes; Limited Information Is Available on QualityGAO-21-92: Published: Jan 4, 2021. Publicly Released: Jan 4, 2021.
Dec 22, 2020
-
Defense Health Care:
Efforts to Ensure Beneficiaries Access Specialty Care and Receive Timely and Effective CareGAO-21-143: Published: Dec 22, 2020. Publicly Released: Dec 22, 2020.
Dec 16, 2020
-
Medicaid Long-Term Services and Supports:
Access and Quality Problems in Managed Care Demand Improved OversightGAO-21-49: Published: Nov 16, 2020. Publicly Released: Dec 16, 2020.
Dec 14, 2020
-
Drug Pricing Program:
HHS Uses Multiple Mechanisms to Help Ensure Compliance with 340B RequirementsGAO-21-107: Published: Dec 14, 2020. Publicly Released: Dec 14, 2020. -
Substance Use Disorder:
Reliable Data Needed for Substance Abuse Prevention and Treatment Block Grant ProgramGAO-21-58: Published: Dec 14, 2020. Publicly Released: Dec 14, 2020.
Dec 10, 2020
-
Indian Health Service:
Actions Needed to Improve Oversight of Provider Misconduct and Substandard PerformanceGAO-21-97: Published: Dec 10, 2020. Publicly Released: Dec 10, 2020. -
Clinical Labs:
Studies Suggest Biopsy Specimen Misidentification and Contamination Errors Are InfrequentGAO-21-59: Published: Nov 10, 2020. Publicly Released: Dec 10, 2020.
Dec 7, 2020
-
Medicaid:
CMS Needs More Information on States' Financing and Payment Arrangements to Improve OversightGAO-21-98: Published: Dec 7, 2020. Publicly Released: Dec 7, 2020.
Dec 1, 2020
-
Military Health Care:
Defense Health Agency Processes for Responding to Provider Quality and Safety ConcernsGAO-21-160R: Published: Dec 1, 2020. Publicly Released: Dec 1, 2020.
Looking for more? Browse all our products here