State Medicaid drug list troubles some

NASHUA – The state Medicaid director says a month-old policy requiring Medicaid clients to use prescription drugs from a list of lower-cost brands could save the state between $6 million and $10 million a year – without interfering in the doctor-patient relationship.

But the policy looks better on paper than it does in practice, say some area health care professionals.

“We strongly support it because it saves the state money on Medicaid prescriptions,” said Gary Wingate, a registered pharmacist who owns and operates Wingate’s Pharmacy on Main Street. “What I don’t like is that it’s our job to stop and call the doctor (about changing the prescription).”

Steve Norton, the state Medicaid director, said his office mailed notices to physicians and pharmacists in advance of the policy change. Health care professionals were told of the new drug formulary – a list of prescription medications approved for use under the policy – and also assured that the state would pay for prescriptions ordered in a three-day period during the changeover.

“This is a big change for the Medicaid program as it tries to implement industry standards,” Norton said in a telephone interview. “We expect some irritation as the rubber meets the road.”

Wingate, who estimated that about a third of his customers are beneficiaries of the state and federal medical insurance program for the poor, said the new policy is costing him time for which he isn’t reimbursed – a double whammy when added to the 33 percent Medicaid reimbursement cut the state has passed on to pharmacists over the past two years.

“We’re in transition. It’s needs a little more time,” Wingate said. “It’s going to optimize costs to the taxpayers, (but) I wish we had a more open forum with the government on these issues.”

Norton said the preferred drug list was developed to control rapidly increasing Medicaid prescription drug costs, which cost the state $130 million last year – about 17 percent of the program’s $750 million budget.

Norton said the new drug list affects fewer than 2 percent of Medicaid prescriptions and provides an extension of between six months and a year for patients taking medications for mental illness. Moreover, while the policy encourages doctors to prescribe from the preferred drug list, it also allows them flexibility in cases of “medical necessity.”

“This is not to interfere in the doctor-patient relationship, but to make sure doctors are (considering) cost-effectiveness,” Norton said. “It’s a process that allows any physician to prescribe any medication if it’s clinically appropriate.”

According to the new policy, however, physicians and other medical practitioners who prescribe must make a written appeal to override the formulary. A doctor must prove that the patient first tried the preferred drug and that it was ineffective.

“It’s a real problem,” said Dr. Lila Monahan, a pediatrician with Partners in Pediatrics, a city practice affiliated with Southern New Hampshire Medical Center. “Particularly with patients on two classes of ADHD medications, allergy medications. But it’s probably true across a lot of different classes. They’re on medication that’s working and now they have to switch.”

Monahan said it frequently takes time to tweak both medication and dosing when treating a child with attention deficit hyperactivity disorder or allergies. So when a protocol works, she is reluctant to make changes. She does not want to upset a child who is stable and doing well.

“Every patient reacts differently to different medications in the same drug class,” said the pediatrician, adding that for children, a change in medication can affect not only health, but also school performance and behavior.

She said some children do well on the first medication she prescribes, while others require several trials before something works.

The new policy has another downside aside from the clinical one, she said. To prescribe a medication not on the preferred drug list, or PDL, a physician must fill out a number of forms – a drain on the administrative staff and office budget.

“In theory, the PDL is great. It can help control costs using evidence-based medicine,” Monahan said. “My fear is that a lot (of drugs on the list) are not based on evidence-based medicine but are purely financial, and I don’t think it’s at all good for kids in the state.”

But adult patients, too, could be at a medical disadvantage, said Dr. Linda Sheldon, an internal medicine physician affiliated with St. Joseph Hospital.

For example, under the formulary, Sheldon must prescribe short-acting pain medication that could lead to addiction. Longer-acting painkillers, which a patient takes once a day, are less addictive, but not on the PDL, Sheldon said.

“I can’t use (the longer acting drugs) without going through the rigmarole,” Sheldon said.

Furthermore, while state officials have compared the Medicaid formulary to ones used by private insurance companies, Sheldon said the state program reimburses at a drastically lower rate.

“The difference between (private) insurance and Medicaid is (Medicaid) pays cents on the dollar,” she said. “Add to that the complexity, the layers of bureaucracy, this makes Medicaid patients even less attractive.”

She said some medical practices have limited or refused Medicaid patients because of low reimbursements. The new policy could further discourage physicians from accepting Medicaid beneficiaries – patients who are already disadvantaged by poverty and complex health and social problems.

But while Sheldon was critical of limits on her ability to prescribe and the potential for reduced access to care for Medicaid patients, she said the PDL is not without some merit.

“Are there some pluses to it? Yes,” she said, noting that at times, because of the rule, she has taken a second look at a patient’s prescription needs.