Access and Utilization of New Antidepressant and Antipsychotic Medications. A. Defining Access

01/01/2000

Simply stated, "Access" to a particular health care service may be defined as the set of factors that affect the potential ability of an individual or a group to acquire timely and appropriate use of that service. Traditionally, access to health care services has been limited by race, gender, age, and class.7 These factors cannot be controlled by the design of the health care system. Health care payers have more direct control over access via the design of their benefit programs. Among these, four principal factors affect access to pharmaceuticals. These include:

  • Pharmaceutical benefit characteristics (e.g., coverage, cost sharing, coverage policies);
  • Formularies;
  • Prior authorization requirements; and
  • Step care protocols.

Under step care programs, physicians are required to attempt to treat a patient with a designated first-line drug and document treatment failure or patient intolerance prior to using another "reserved" agent. In general it is thought that the designated first-line drug is an older, often cheaper, and perhaps less effective drug than the reserved drug. Alternatively, patients may be required to try a new-generation, formulary drug before being given reimbursement for another non-formulary, new-generation drug. Step care programs are similar to prior authorization programs in that they often serve to control prescribing practices.​