As Texas considers changes to the state’s Medicaid program, access to physician directed-care is in jeopardy. Changes to the list of covered prescription drugs, known as formularies, would allow insurers — not physicians — to determine what medications managed care plans would cover.
These changes, intended to cut costs, could result in medical complications that hurt the vulnerable people served by the Medicaid program and cost the state more in the long run.
Research shows restrictive formularies often lead to greater spending on medical complications that outweigh any short-term savings. Take, for example, epilepsy medications, which are not interchangeable. Access to epilepsy medications leads to greater seizure control and fewer hospitalizations, which in turn means lower costs.
Individuals often react quite differently to epilepsy medications, and each medication comes with its own side effects, which often can be significant enough to compromise patients' quality of life and cause them to abandon their treatment. People living with epilepsy need meaningful access to the full range of treatments available — and the specialists who know how to prescribe them.
In selecting appropriate epilepsy medication, physicians must consider a number of variables, including type and frequency of seizures, age, gender and health conditions. It also often requires trial and error, along with close observation of blood levels and side effects. Texas Medicaid’s current open access for epilepsy medications ensures meaningful and timely access to epilepsy care.
The human toll of uncontrolled seizures is significant and extends beyond the person living with epilepsy. Delaying access to medications and interrupting proven treatment regimens leads to breakthrough seizures, related complications and increased medical costs due to preventable seizures, including accidents, emergency room visits and hospitalizations. Along with a decreased quality of life and costly health complications, there’s also the lost wages and productivity for individuals living with epilepsy, their families and their communities.
As the state considers changes to Medicaid, it should remember that prescription drug costs for the program are within the national average and that the majority of the prescriptions are for generic formulations. Restrictive formularies that promise additional savings at the expense of access to physician-directed care for people living with complex chronic conditions would harm the program’s most-vulnerable beneficiaries and lead to medical complications that will cost the state more in the long run.
We can achieve greater savings — and greater protections for patients and public safety — by ensuring formularies provide access to a wide range of medications for the vulnerable populations served by the Medicaid program.
Over the years, Texas has recognized the importance of quality epilepsy care by preserving open access to epilepsy medications in the Medicaid program. Like Texas, many states and the federal government offer similar protections by placing epilepsy medications in a protected class in Medicaid and Medicare.
Despite the challenges faced by people living with epilepsy, timely access to the right medications results in seizure control for the majority of people living with epilepsy. Preserving the current single formulary and the protections for medications for the most vulnerable beneficiaries – which ensure physicians, not insurers, make medication decisions — will lead to a better quality of life and long-term savings to the state.