The Wyoming Department of Health (WDH) has successfully used Wyoming Medicaid data to reduce the costs unnecessarily spent on a children’s medications. Respiratory Syncytial Virus (RSV) is a contagious viral disease that can lead to serious health problems in some people and is quite common in infants and young children.
Synagis is a prescription medication given in a series of injections to help prevent severe lung disease in children that are at high risk of RSV complications.
In 2010, a review of key Wyoming Medicaid data showed significant statewide growth in Synagis use. During the 2010 RSV season peak, the average number of Synagis doses per patient increased greatly and resulted in an annual cost of more than $2.5 million.
“Our data showed that the drug was being prescribed routinely for children who did not have a high risk of complications and for those children over 24 months”, said Dr. James Bush, Wyoming Medicaid’s Medical Director with WDH. “While we were mindful of the costs, we also had concerns that improper drug use would expose the young patients to side effects.”
In cooperation with a committee that included outside pharmacists and doctors, the Wyoming Medicaid staff established a Synagis prior authorization process. Doctors prescribing Synagis were required to provide justification and clinical information before payment for Synagis could be approved for their Medicaid patients.
“After the new process began, we saw a significant decline in the overall use of Synagis for the state’s Medicaid patients”, Bush said. “Follow up research using Medicaid claims data showed no significant increase in RSV diagnosis rates, RSV related hospitalization rates, length of RSV related hospital stays, or RSV related mortality. In other words, despite a 64 percent reduction in Synagis doses administered, we found no harmful health effects among our Medicaid clients.”
According to Teri Green WDH Division of Healthcare Financing Senior Administrator and State Medicaid Agent, said, “This effort is an example of how working together with Wyoming’s healthcare providers and using detailed analysis of data to identify expense trends, we can respond with smart clinical rules and practice standards to reduce waste without harming our clients’ health”.