An Evaluation Of Oregon s Evidence-Based Practitioner- Managed Prescription Drug Plan

Transcription

1 Oregon s Drug Plan An Evaluation Of Oregon s Evidence-Based Practitioner- Managed Prescription Drug Plan Oregon s effort to manage drug usage helped curb spending, but health outcomes for patients have not been ascertained. by Daniel M. Hartung, Kathy L. Ketchum, and Dean G. Haxby ABSTRACT: This paper describes Oregon s implementation of its publicly developed, evidence-based, Practitioner-Managed Prescription Drug Plan (PMPDP). Oregon s PMPDP was initially self-enforced with a dispense as written (DAW) exception process, followed by an educational prior authorization (soft PA) method, and finally no active enforcement. Marketshare trends indicate that the educational prior authorization process was most effective at increasing the use of preferred agents. Pharmacy costs decreased 9.1 percent and 17.7 percent after implementation of the DAW and soft PA policies, respectively. Data from nonenforced PMPDP classes showed no change; this suggests the need for effective methods to encourage PMPDP compliance. [Health Affairs 25, no. 5 (2006): ; /hlthaff ] Sharp declines in revenues combined with rapidly rising health care spending have forced many states to adopt far-reaching measures to sustain their Medicaid programs. 1 Prescription drugs are a key driver of health care costs for state Medicaid programs and a frequent target for cost-controlling programs. In response to these pressures, in August 2001 Oregon enacted Senate Bill (SB) 819, which mandated development of the Practitioner-Managed Prescription Drug Plan (PMPDP) for the fee-for-service (FFS) Medicaid program. 2 The intent of SB 819 was to provide Oregonians the most effective drugs in the most costeffective manner by developing a process that systematically identified the most effective drugs within a class. Preferred drug lists (PDLs) are common among state Medicaid programs; however, Oregon s approach to both establishing and implementing its list was unique. Here we describe the methods used to develop and im- Daniel Hartung is assistant director of research and program evaluation in the Drug Use Research and Management Program, College of Pharmacy, Oregon State University, in Portland. Kathy Ketchum is coordinator of Medicaid-related programs. Dean Haxby (haxbyd@ohsu.edu) is an associate professor of pharmacy and director of the Drug Use Research and Management Program. HEALTH AFFAIRS ~ Volume 25, Number DOI /hlthaff Project HOPE The People-to-People Health Foundation, Inc.

2 DataWatch plement the PMPDP, examine prescription drug use after it took effect, and estimate cost savings attributable to this policy. PMPDP list development process. Establishment of the Oregon PMPDP was predicated on a several-step process outlined in the original legislation. First, SB 819 asserted that Oregon Medicaid enrollees should have access to the most effective prescription drugs for their clinical conditions. Effectiveness was to be determined by health practitioners, who are informed by the latest peer-reviewed research. Finally, cost was to be considered only after the relative clinical effectiveness was established and then managed through market competition. Comparative effectiveness was evaluated using a systematic process; employing established methods of evidence-based medicine; and open to input from the public, stakeholders, and the pharmaceutical industry. 3 The use of an evidence-based approach for policy development is not novel;however,thescopeandtransparency of Oregon s process makes it unique among both public and private health care payers. 4 Theevidence-basedreviewprocesshasbeenreviewedindetailelsewhere. 5 The first step in the process developed key effectiveness and safety questions. To build community consensus about what effectiveness and safety outcomes were important, volunteer committees of local health care practitioners and members of the public were convened to develop the questions. Clinicians were restricted from participating in the subcommittees if they had major financial conflicts of interest. Key questions varied by drug class but generally focused on the comparative effectiveness, drug safety, and differential effects among subpopulations (for example, by sex, age, or race). Draft questions were posted to a Web site to allow publicreview,comment,andtestimony. 6 Once finalized, key questions were submitted to an Evidence-based Practice Center (EPC) to conduct the literature search and systematic evidence review. For each drug class, the EPC conducted a systematic literature search identifying the key peer-reviewed studies relevant to each specific key question. Comprehensive reports generated by the EPC were used by the committees, in conjunction with public comment and testimony, to determine which drugs were most effective and safe within the class as dictated by the key questions. Committee reports were submitted to the Oregon Department of Human Services for price determination. If the practitioner committee determined that the evidence did not support clinically meaningful differences between drugs within a class, then all comparatively effective drugs, competitively priced to the least expensive (benchmark) agent, were selected as preferred drugs on the PMPDP. A standing update committee was also established to meet regularly and evaluate new evidence or new drugs in the reviewed classes based on a preliminary EPC-generatedupdatereport.Iftheupdatecommitteebelievedthatnewconclusions would be drawn, the drug-specific practitioner committees were reconvened with the standing update committee for a review of the new evidence September/October 2006

3 Oregon s Drug Plan Implementation. The first four reviewed drug classes were implemented in August (proton pump inhibitors, or PPIs, and long-acting opioids) and September (nonsteroidal anti-inflammatory drugs, or NSAIDs, and statins) Initially, the PMPDP was practitioner-enforced, and prescribers were given a simple way to prescribe off the list. If a prescriber determined that a patient required a nonpreferred PMPDP medication, the prescriber had the option of writing dispense as written (DAW exception) on the prescription to notify the pharmacist to override the policy. Dispensing pharmacists played a key education role during this period, because they were responsible for notifying prescribers of the need for an override. Because the initial changes in use did not meet anticipated budget targets, the state implementedanadministrativeruleinmay2003requiringprescriberstocontactthe state s pharmacy benefit administrator to hear an educational message about the comparative evidence. The soft prior authorization (PA) did not require the prescriber to use a preferred agent or submit justification for the nonpreferred selection. Only the first four classes were subject to these enforcement policies (DAW exemption, soft PA). In October 2003, legislation was passed that prohibited any active enforcement of the PMPDP, thereby revoking the soft PA administrative rule. 7 All classes added subsequent to October 2003 have not been subject to any enforcement. Under this voluntary process, the PMPDP was expanded in May 2003 to include estrogens and in November 2003 to include overactive bladder drugs, oral hypoglycemics, skeletal muscle relaxants, and triptans. Evaluation Methods Prescription drug claims from January 2001 through June 2004 were used to evaluate the impact of the various enforcement methods on the first four drug classes (PPIs, NSAIDs, long-acting opioids, and statins). There was a thirty-fourday supply limit on dispensed drugs during the evaluation period. Usage over the study period was divided into four distinct time periods: pre-policy period (1 January 2001 through 31 July 2002 or 31 August 2002 for PPIs and long-acting opioids, or NSAIDs and statins, respectively), DAW exception period (1 August 2002 or 1 September 2002, depending on class, through 30 April 2003), soft PA period (1 May 2003 through 30 September 2003), and voluntary period (1 October 2003 through 30 June 2004). The proportion of prescriptions dispensed as preferred PMPDP agents (PMPDP market share) was quantified and averaged over each period. Changes in market share were quantified as the relative change of one period overtheprevious.thelistwasdynamicbecausethepreferredpmpdpagents changed depending on pricing variation or the emergence of new evidence (such as new outcome evidence for atorvastatin within statin class). To better account for these list changes, the proportion of prescriptions dispensed as the PMPDP benchmark agent, which did not change during the evaluation period, was evaluated similarly. Market-share trend analyses were also conducted on the drug classes that were not subject to direct enforcement (for example, triptans, oral HEALTH AFFAIRS ~ Volume 25, Number

4 DataWatch hypoglycemics, overactive-bladder drugs, and skeletal-muscle relaxants) eight months before and after they were added to the PMPDP. Estrogen use was not evaluated because of the concomitant changes in prescribing occurring as a result oftherecentnegativefindingsabouthormonereplacementtherapy. 8 A cost analysis was performed for the NSAIDs, long-acting opioids, PPIs, and statins. Cost trends were estimated using the ingredient cost per enrolled member per month and adjusted for federal and supplemental rebates. A segmented ordinary least squares linear regression analysis on class-specific and total cost per member per month was performed using the time segments described above. 9 Coefficientsreflectingaone-timeimmediatechangearepresentedasthepercentage difference of the expected trend if the policy had not been implemented. Changes in trend are reported as the absolute increase or decrease in slope. Statistical analyses were performed with SAS version 9.1. Program savings were estimated taking the difference between a linear projection of total cost per member per month and the observed cost per member per month adjusted for the cost of administering the soft PA during that time. In January 2003, in the midst of a major budget shortfall, the OHP reorganized its Medicaid program into two distinct benefit packages that differed in benefit structure: Oregon Health Plan (OHP) Plus and OHP Standard. 10 Another component of the restructuring involved instituting various cost-sharing mechanisms such as copayments for drugs and services, which varied dramatically between the OHP Plus and OHP Standard populations. Most notably, OHP Standard enrollees were required to pay copays between $3 for generics and $15 for brandname prescription drugs. Clients enrolled in OHP Plus were asked, but not required, to pay copays of between $2 for generics and $3 per brand-name prescription. To minimize the confounding effects of this policy, we excluded all OHP Standard benefit recipients from our analysis. Study Results Market share. The average monthly enrollment in the OHP FFS program during the months of our study was 129,021; it remained relatively stable throughout. The average fluctuation from month to month was 1.8 percent. During the evaluation period, the PMPDP and how it was enforced changed several times, particularly for the first four classes reviewed (Exhibit 1). In addition to the two policy changes, two major PMPDP preferred list changes occurred during the evaluation period. In April 2004, Zocor, Lescol, Lescol XL, Lipitor, and Altocor were added to the preferred statin list. Duragesic was removed from the long-acting opioid list in November To adjust for these drug changes, we performed another analysis of percentage of prescriptions dispensed as the PMPDP benchmark (lowest-cost agent) (Exhibit 2). The benchmark agents for the initial four classes remained constant during the evaluation period. The average monthly market-share figures for each 1426 September/October 2006

5 Oregon s Drug Plan EXHIBIT 1 Monthly Market Share For Drugs In The Oregon Practitioner-Managed Prescription Drug Plan (PMPDP), By Drug Class, January 2001 June 2004 Percent PMPDP preferred 100 All statins added except Crestor PPIs Long-acting opioids NSAIDs Duragesic removed 0 Statins DAW policy Soft PA Voluntary 1/01 7/01 1/02 7/02 1/03 7/03 SOURCE: Oregon Health Plan fee-for-service pharmacy claims data, various years. NOTES: Proportion of prescriptions in four initially implemented drug classes dispensed as PMPDP preferred drugs. PPI is proton pump inhibitor. NSAID is nonsteroidal anti-inflammatory drug. DAW is dispense as written. PA is prior authorization. Because there are two possible starting dates for the DAW period (August or September 2002), two gray lines are shown. 1/04 policy period for all preferred and benchmark drugs are shown in Exhibit 3. The statin class was the most profoundly affected by the PMPDP implementation. After the DAW exception was activated, market share of preferred agents increased 28 percent overall. Market share for preferred statins doubled, and preferred NSAID use increased the least. After the soft PA was employed, the use of preferred products in aggregate increased 43 percent, from 58 percent to 82 percent. Again, the use of preferred statins demonstrated the greatest increase, followed by NSAIDs. Preferred PPI market share increased the least. When the soft EXHIBIT 2 Benchmark Market Share For Drugs In The Oregon Practitioner-Managed Prescription Drug Plan (PMPDP), By Drug Class, January 2001 June 2004 Percent PMPDP preferred 80 DAW policy Soft PA Voluntary 60 PPIs /01 7/01 1/02 7/02 1/03 7/03 Statins NSAIDs Long-acting opioids 1/04 SOURCE: Oregon Health Plan fee-for-service pharmacy claims data, various years. NOTES: Proportion of prescriptions in four initially implemented drug classes dispensed as benchmark drugs. PPI is proton pump inhibitor. NSAID is nonsteroidal anti-inflammatory drug. DAW is dispense as written. PA is prior authorization. Because there are two possible starting dates for the DAW period (August or September 2002), two gray lines are shown. HEALTH AFFAIRS ~ Volume 25, Number

6 DataWatch EXHIBIT 3 Summary Of The Oregon Practitioner-Managed Prescription Drug Plan (PMPDP) Market Share, January 2001 July 2004 DAW exception (%) Soft PA (%) Voluntary (%) Drug class: PMPDP preferred Baseline Market share Percent change Market share Percent change Market share Percent change PPI Long-acting opioid NSAID Statin Aggregate Benchmark PPI (Protonix) Long-acting opioid (LA- Morphine) NSAIDs (Naproxen) Statins (Lovastatin) SOURCE: Authors analysis based on Oregon Health Plan fee-for-service pharmacy claims. NOTES: Proportion of prescriptions dispensed as a PMPDP preferred drug and benchmark drug for initially implemented drug classes during each of the four policy segments (see text for time periods involved). For each policy change, the average monthly proportion and the percentage change compared with the previous period are reported. Baseline period for statin benchmark only includes time when commercially available (January August 2002). PPI is proton pump inhibitor. NSAID is nonsteroidal anti-inflammatory drug. PA policy was retracted, overall PMPDP preferred market share decreased overall 17 percent. NSAIDs showed the largest decrease. The 37 percent reduction in preferred long-acting opioid use was attributable to the removal of Duragesic as a preferred agent. When we restricted the market-share analysis to just the benchmark drug, generic long-acting morphine use dropped only 4 percent. Generally speaking, the benchmark drug market-share trends followed a pattern similar to that of the overall preferred PMPDP market share. Overactive-bladder drugs, skeletal-muscle relaxants, oral hypoglycemics, and triptanswereaddedtothepmpdpinnovember2003.asidefrombeingpostedon the Medicaid Web site, no formal policies were implemented to encourage their use. No discernible changes in the use of preferred drugs were observed after these classes were added to the PMPDP (Exhibit 4). Cost analysis. Exhibit 5 shows the results of the segmented regression models. The aggregate model demonstrates that implementation of the DAW exception was associated with a 9.1 percent immediate per member per month cost decrease, as well a significant reduction in overall trend. The soft PA period was associated with a 17.7 percent immediate decrease, along with a significant increase in slope of $0.28. Within the specific classes, our model showed that the DAW period was associated with statistically significant abrupt declines of percent. Significant immediate decreases of percent were detected after establishment of the soft PA. Elimination of the soft PA was not accompanied by any statistically sig September/October 2006

7 Oregon s Drug Plan EXHIBIT 4 Market Share Of Nonenforced Practitioner-Managed Prescription Drug Plan (PMPDP) Drug Classes, Before And After Listing On PMPDP, 1 November 2003 Market share Drug class Before (%) After (%) Percent change Skeletal muscle relaxants Urinary incontinence Oral hypoglycemics Triptans SOURCE: Authors analysis based on Oregon Health Plan fee-for-service pharmacy claims. NOTES: Proportion of prescriptions dispensed as a PMPDP preferred agent for nonenforced classes eight months before and after listing on PMPDP. The average monthly proportion and the percentage change (in percentage points) compared with the previous period are reported. EXHIBIT 5 Regression Results: Segmented Linear Regression Models Of Individual Class And Aggregate Costs Per Member Per Month, Oregon Practitioner-Managed Prescription Drug Plan (PMPDP), January 2001 June 2004 Drug class Baseline Aggregate PPI Long-acting opioid NSAID Statin Intercept Baseline trend $5.30** ($5.09, $5.51) $0.18** ($0.16, $0.19) $0.84** ($0.73, $0.94) $0.05** ($0.04, $0.06) $2.22** ($2.07, $2.36) $0.06** ($0.05, $0.07) $1.35** ($1.28, $1.42) $0.02** ($0.01, $0.02) $0.93** ($0.88, $0.98) $0.05** ($0.04, $0.05) DAW exception policy initiated Immediate change Trend change 9.1%** ( 13.8%, 4.3%) $0.18** ( $0.08, $0.02) 6.7% ( 17.2%, 3.9%) $0.05** ( $0.05, $0.03) 9.9%** ( 17.4%, 14.2%) $0.01 ( $0.06, $0.01) 14.6%** ( 22.5%, 6.6%) $0.04** ( $0.07, $0.03) 8.8%** ( 13.7%, 3.9%) $0.05** ( $0.08, $0.02) Soft PA policy initiated Immediate change Trend change 17.7%** ( 25.4%, 10.0%) $0.28** ($0.11, $0.44) 10.1% ( 26.5%, 6.2%) $0.06 ( $0.01, $0.14) 17.5%** ( 27.9%, 7.2%) $0.08 ( $0.02, $0.19) 42.0%** ( 56.5%, 27.4%) $0.01 ( $0.05, $0.06) 11.0%** ( 19.3%, 2.8%) $0.07 ($0.03, $0.11) Voluntary policy initiated Immediate change Trend change 5.5% ( 1.1%, 12.1%) $0.10 ( $0.26, $0.06) 2.8% ( 16.1%, 10.4%) $0.02 ( $0.10, $0.05) 4.4% ( 4.6%, 13.3%) $0.10 ( $0.20, $0.00) 46.6%** (22.5%, 70.7%) $0.06** ($0.01, $0.11) 9.0%** (2.6%, 15.5%) $0.02 ( $0.06, $0.02) SOURCE: Authors analysis based on Oregon Health Plan fee-for-service pharmacy claims. NOTES: Immediate changes are expressed as percentage change from expected. Trend changes are expressed as absolute change in change in slope from previous period (see text for time periods involved). 95 percent confidence intervals are in parentheses. PPI is proton pump inhibitor. NSAID is nonsteroidal anti-inflammatory drug. DAW is dispense as written. PA is prior authorization. **p <.05 HEALTH AFFAIRS ~ Volume 25, Number

8 DataWatch nificant change in aggregate cost per member per month. However, immediate 46.6 percent and 9.0 percent increases in costs were observed in the NSAID and statin class, respectively, after the soft PA was repealed. Exhibit 6 shows observed and predicted spending for the first four PMPDP classes before and after the two policies were implemented. Overall, we estimate that the DAW exception was responsible for an average monthly reduction of $1.41 per member per month (95 percent confidence interval: $0.80, $2.78), or $191,932 in total (95 percent CI: $108,456, $275,409) in monthly savings. The PA policy was projected to reduce spending by $3.58 per member per month (95 percent CI: $2.78, $4.37) or a total of $444,660 (95 percent CI: $363,205, $570,870) per month. During the entire period, the DAW policy and soft PA saved an estimated $1,727,392 (95 percent CI: $976,102, $2,478,682) and $2,223,300 (95 percent CI: $1,816,027, $2,854,353) in pharmacy costs, respectively. Discussion This analysis, which focused on the implementation of the PMPDP, demonstrated that the use of both a DAW exception and a soft PA method were effective at reducing spending and shifting market share within the four initially implemented drug classes in the PMPDP. The DAW exception policy shifted market share toward preferred agents by 28 percent. The market share of preferred agents rose another 43 percent after the soft PA took effect. Revocation of these policies in October 2003 for the initial classes has contributed to a reversal of previously established market-share gains. NSAIDs and long-acting opioids experienced the largest reversal of preferred drug market share after the soft PA was eliminated. Negligible market-share changes occurred in classes that were not subject to any EXHIBIT 6 Cost Prediction Model: Aggregate Per Member Per Month Costs Predicted And Observed Over Time For Four Initial Oregon Practitioner-Managed Prescription Drug Plan (PMPDP) Drug Classes, January 2001 June 2004 Dollars Observed Predicted 95% CI DAW policy Soft PA Voluntary 1/01 7/01 1/02 7/02 1/03 7/03 1/04 SOURCE: Authors analysis based on Oregon Health Plan fee-for-service pharmacy claims data, various years. NOTES: Prediction model is of the form y = ß0 + ß 1 x 1, for model p <.0001, adjusted R 2 = CI is confidence interval. DAW is dispense as written. PA is prior authorization September/October 2006

9 Oregon s Drug Plan active enforcement policy. Cost savings were estimated to occur in the initial PMPDP drug classes under both enforcement strategies. Total per member per month costs were reduced significantly, as both an immediate reduction and a decrease in the month-to-month trend, for both the DAW policy and soft PA. These decreases translate into approximately $4 million in pharmacy program savings over the life of both policies. It is estimated that almost 70 percent of state Medicaid programs use PDLs to assist in managing drug spending. 11 However, similar to other drug management strategies, little is known about these policies impact on economic or health outcomes. 12 The general lack of information about PDLs is further compounded by the considerable heterogeneity with respect to how PDLs are synthesized and enforced in various state Medicaid programs. Although nearly all states use clinical evidence to help decide which drugs will be included on their lists, Oregon is unique in the explicit process it uses to evaluate and compare this evidence. Both the DAW exception and educational soft PA enforcement methods were also unique among Medicaid programs. Study limitations. Several important limitations of our study should be considered. One potential confounding factor was the implementation of a patient copay policy in January of Prescription drug cost-sharing policies have been demonstrated to reduce use and potentially shift market share. Although we attempted to control for this by excluding clients who faced the highest copayment schedule, it is impossible to completely eliminate its effect. Trends described in Exhibits 1, 2, and 6 do not appear to show any major effect after the copay policy was implementedinjanuary2003.thisanalysisdidnotevaluateimpactonuseofother health services. Several of the shifts in PMPDP use were large enough that a closer evaluation of unintended health outcomes will be critical in assessing this program s overall impact. In addition, the added administrative burden for health care providers caring for OHP enrollees was not formally considered in this analysis. Concerns about the process. Many have expressed concerns and skepticism about the process in which Oregon has translated clinical evidence into policy. Challenges to the process include developing questions that adequately capture important outcomes, identifying and evaluating unpublished data, the insufficient quantity of high-quality research, lack of direct comparative studies between drugs, how to appropriately integrate evidence from observational research, and how to fairly deal with potential conflicts of interest at several levels. Also, the reviews focused only on comparing agents within a class and did not compare agents from different classes that could be used for the same condition. Finally, while the EPCgenerated reviews made no claims of therapeutic equivalence when evidence was lacking to suggest a difference between drugs within classes, the state made its preferred drug selections based on this assumption. Some have argued that agents should not be selected for the PDL when evidence is lacking to establish whether or not a true difference exists. 13 HEALTH AFFAIRS ~ Volume 25, Number

10 DataWatch Oregon has adopted a unique system for translating the principles of evidence-based medicine into policy decisions regarding the use of prescription drugs. However, translating this research into meaningful changes in practice has lagged somewhat because of lack of enforcement mechanisms aimed at encouraging preferred drug use. Our data suggest that for an evidence-based PDL to have an impact on drug use or costs, effective methods of promoting evidence-based choices need also be employed. Data from nonenforced classes suggest that having an evidence-based process to determine preferred agents alone is not sufficient for changing prescribing behavior. The state is now using educational techniques such as faxed prescription-change forms and provider detailing to disseminate research generated from the comparative reviews. This work was supported by the Oregon State University College of Pharmacy, which receives funding from the Oregon Office of Medical Assistance Programs. NOTES 1. J. Crowley, D. Ashner, and L. Elam, Medicaid Outpatient Prescription Drug Benefits: Findings from a National Survey, December 2003, (accessed 30 May 2006); M.M. Mello, D.M. Studdert, and T.A. Brennan, The Pharmaceutical Industry versus Medicaid Limits on State Initiatives to Control Prescription-Drug Costs, New England Journal of Medicine 350, no. 6 (2004): ; and J.K. Iglehart, The Dilemma of Medicaid, New England Journal of Medicine 348, no. 21 (2003): Oregon Legislative Assembly Senate Bill 819, 71st Oregon Legislative Assembly, 2001 Regular Session. 3. Drug Effectiveness Review Project, Quality Assessment Methods for Drug Class Reviews for the Drug Effectiveness Review Project, (accessed 13 February 2006). 4. A.M. Garber, Evidence-based Coverage Policy, Health Affairs 20, no. 5 (2001): C. Bernasek et al., Oregon s Medicaid PDL: Will an Evidence-based Formulary with Voluntary Compliance Set a Precedent for Medicaid? January 2004, (accessed 18 April 2006). 6. Oregon s Practitioner-Managed Drug Plan, Evidence-based Medicine Reports, DAS/OHPPR/ORRX/HRC/evidence_based_reports.shtml (accessed 18 April 2006). 7. Oregon Legislative Assembly House Bill 3624, 72d Oregon Legislative Assembly, 2003 Regular Session. 8. J.E. Rossouw et al., Risks and Benefits of Estrogen plus Progestin in Healthy Postmenopausal Women: Principal Results from the Women s Health Initiative Randomized Controlled Trial, Journal of the American MedicalAssociation 288, no. 3 (2002): ; and D. Grady et al., Cardiovascular Disease Outcomes during 6.8 Years of Hormone Therapy: Heart and Estrogen/Progestin Replacement Study Follow-up (HERS II), Journal of the American Medical Association 228, no. 1 (2002): A.K. Wagner et al., Segmented Regression Analysis of Interrupted Time Series Studies in Medication Use Research, Journal of Clinical Pharmacy and Therapeutics 27, no. 4 (2002): Details about the modeling process are described in an online appendix, available at 25/5/1423/DC C. Mann and S. Artiga, The Impact of Recent Changes in Health Care Coverage for Low-Income People: A First Look at the Research following Change in Oregon s Medicaid Program, Issue Paper, June 2004, (accessed 13 February 2006). 11. Crowley et al., Medicaid Outpatient Prescription Drug Benefits. 12. S.B. Soumerai, Benefits and Risks of Increasing Restrictions on Access to Costly Drugs in Medicaid, Health Affairs 23, no. 1 (2004) J.D. Kleinke, Evidence-based Medicine: Health Care s Next Holy War, Journal of Managed Care Pharmacy 11, no.4supp.(2005):s3 S6;andR.Padrezetal.,The Use of Oregon s Evidence-based Reviews for Medicaid Pharmacy Policies: Experiences in Four States, May 2005, (accessed 18 April 2006) September/October 2006