Problems Could Add to Physician Medicaid Exodus
July 23, 2016
tape in the Medicaid prescription drug program hinders some low-income children
and adult patients across Texas from timely getting necessary medications
prescribed by their physicians, according to the Texas Medical Association’s
(TMA’s) Texas Medicine magazine. The
problem occurs when physicians prescribe some “preferred” medications listed
under the Medicaid Preferred Drug List (PDL) but the drug is subject to additional
review, unbeknownst to the physician. When the patient tries to fill the
prescription at the pharmacy, it is denied, and the patient has to return to
the physician for help. At a time when the program is under legislative review,
TMA is recommending improvements.
Preferred or Not?
Medicaid operates a PDL where most prescription drugs are classified as
preferred or nonpreferred. Drugs in the preferred category do not require preauthorization
— physicians getting approval before prescribing them — when prescribed under
Medicaid. However, despite the Medicaid preapproval, patients and their
physicians discover some prescriptions on the PDL require additional, unexpected
approval before patients can get their drugs. These additional requirements are
not well publicized. “I have no way of knowing these things ahead of time until
those prescriptions get kicked back to me,” said Ryan Van Ramshorst, MD, a San
Antonio pediatrician. “It makes it very challenging as
a provider to get medications to kids who need them.
And my office is not set up to do prior authorizations so I do them myself, and
it takes a lot of my time,” said Dr. Van Ramshorst, a member of TMA’s Select
Committee on Medicaid, CHIP, and the Uninsured. He cites one child who nearly
had to be hospitalized as a result of this drug delay and others whose
successful, common asthma-control medication was suddenly denied.
PDL perplexes doctors partly because the state of Texas and roughly 20
Medicaid HMOs comanage it. When the legislature established this arrangement,
the intent was to ensure a single, statewide PDL with which all Medicaid HMOs
must comply. But the HMOs are not required to follow all so-called “clinical
edits” that subject some drugs to additional review, creating confusion. (Clinical
edits are additional quality and safety checks by the state.) Some of these
reviews accomplish things such as preventing harmful drug interactions. Yet when
physicians check the PDL, there is no mention that some drugs may be subjected
to this extra step. Plans also can simplify the clinical edits — a good thing —
but the variability across plans sows confusion. And if the plans do not have
to comply with all the edits, some physicians wonder whether they are needed at
element of the program raising eyebrows involves rebates. The program has a
rebate component to save the state money, but physicians wonder if it’s
effective, and whether patient care might be at risk. Federal rule requires pharmaceutical
companies who want their drugs to be covered by Medicaid to pay rebates to the
state. Additionally, Texas and a
handful of other states require companies to pay a supplemental rebate for
their medicine to be considered a preferred
drug, eligible for the PDL. This often results in brand name drugs being preferred. Some doctors
who prescribe less expensive generic drugs whenever possible question a program
whose rebate plan tends to favor more expensive brand-name drugs instead of
cheaper generics. And delay can occur if the doctor prescribes the generic, but
the name brand is in the PDL.
just nuts. It’s amazing to me the vendor drug program [VDP] evolved itself into
this mess where a doctor and a patient are penalized for prescribing the generic
rather than the brand name,” said TMA Physicians Medicaid Congress Chair John
R. Holcomb, MD, a San Antonio pulmonologist. “It’s foreign to our training to
write a generic prescription and have it rejected.” And one physician said sometimes the
name-brand drug is five times more expensive than its generic counterpart.
Doctors Offer Solutions
of these issues, the TMA Physicians Medicaid Congress is pushing for Medicaid reforms and calling for an
administrative overhaul of the drug benefit program to simplify and streamline
requirements. The VDP’s state/HMO comanagement arrangement expires in August
2017, so the legislature must decide whether to keep the current structure or
let the HMOs solely manage the benefit. As it is, Medicaid HMOs are responsible
for 87 percent of all Medicaid patients in Texas, so some believe they should
manage the drug benefit program too. And with fewer than 37 percent of Texas
physicians accept all new Medicaid HMO patients, according to TMA Physician
Survey data, some argue fixing this prescription drug problem might keep that participation
number — which is near “crisis level,” according
to House Public Health Committee Chair Rep. John Zerwas, MD (R-Richmond) — from
shrinking further. One doctor said he has to ask for 10
times more Medicaid prior authorizations than he does under commercial
insurance; reducing the program’s bureaucratic hassle might encourage doctors
TMA recommendations for
streamlining the VDP:
Within each drug class on the preferred drug list, include a reference
so physicians can immediately determine if there are any additional associated
prior authorization criteria (clinical edits) that the state sets and which
HMOs implement them or a less stringent version of them.
When the state Drug Utilization Review Board considers a clinical
edit, publicize the justification for the proposal and the entity that
Evaluate the validity of all current clinical edits, then
establish a schedule to periodically review clinical edits.
For physicians using Epocrates, a mobile health software app,
establish an electronic mechanism so physicians can quickly and easily access
information on clinical edits and which HMOs use them.
Limit changing drugs from PDL or preferred to nonpreferred status
to annual changes.
When a drug’s preferred status changes, provide the rationale.
If there is a drug shortage, adopt an expedited communication plan
so the Texas Health and Human Services Commission and HMOs can quickly share
information with network physicians on medication alternatives.
Allow physicians to prescribe drugs for nonlabeled uses in certain
patient populations when there is clinical evidence supporting such
If the HMOs are given authority to completely manage the benefit,
establish strong statutory consumer and provider protections, including
continuity of care provisions and limits on controversial utilization
management efforts, such as step therapy.
The health plans say they, too, are limited,
by the state.
As for updating physicians
about drug changes, state Medicaid officials are working on a revised VDP website
that would make it easier for doctors to determine which restrictions apply to
a drug, such as whether it is preferred or nonpreferred. But the changes are
not expected to be ready until early 2017.
“The vendor drug program is
still a huge issue and has been for many years. It’s very frustrating, and this
needs to be addressed in the  legislative session," Dr. Van Ramshorst
TMA is the largest state medical society in the nation,
representing more than 49,000 physician and medical student members. It is
located in Austin and has 110 component county medical societies around the
state. TMA’s key objective since 1853 is to improve the health of all Texans.
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