When it comes to right medicines in Medicaid, let doctors, not insurance companies, decide

When it comes to a patient’s health, the old phrase, "The doctor knows best," still rings true, especially for medications.

When the Texas Legislature meets in January, there will be plenty of budget and policy battles waged. The battles fought over one of the most significant state budget drivers — Medicaid — are ones that deserve close attention and scrutiny by taxpayers, patients and health care professionals. It’s not just a money issue, it’s a basic patients’ rights concern.

Some insurance companies are already signaling that they again will attempt to take doctors and other health care providers out of the driver’s seat when it comes to determining which medicines Medicaid patients can receive.

It’s a battle we’ve seen waged in past legislative sessions, and it’s a move by insurers that the Legislature has prudently rejected, acknowledging a common-sense truth: Health care professionals — not insurance companies — are best equipped to make decisions about prescription therapies for their patients.

And under current law, the Texas Medicaid drug formulary works for patients and taxpayers alike. It involves doctors in the development of the Medicaid preferred drug list. It involves patients and patient advocacy groups, ensuring they have the opportunity to participate in and comment on the process. It balances taxpayer costs with patient safety and the efficacy of specific medications. It gives patients access to a wide range of medications to treat their conditions, helping to avoid costly hospital stays and criminal justice system involvement. It requires quick response to prior authorization requests and enables patients to get prescriptions refilled in the emergency room while those authorizations are pending.

Today, Texas runs the nation’s third-largest Medicaid program, yet the state has a lower cost per enrollee for medications than 45 of the 50 states, and its cost per prescription is below the national average.

Despite this success, insurance companies want a program that would give them more power to restrict access to medicines. If insurers had their way, a patient may be denied coverage for a medication based primarily on cost, not taking into account the effectiveness of the medicine or the patient's history of successfully managing her or his medical condition with that product.  

In other words, patients could be required to try a lower-cost drug and wait to see if it “fails” before the originally prescribed medicine would be approved. This is a dangerous practice that disrupts continuity of care and threatens patient health.

At NAMI (National Alliance on Mental Illness) Texas, we are dedicated to improving the quality of life of all individuals living with mental illness and their families, and that means working to ensure acceptance of and the best treatment for all those with mental illness to facilitate recovery.  

Much of the push to this insurer-driven formulary centers on cost, but unfortunately, it’s highly doubtful that the insurers’ proposal would save taxpayers a dime.

Under federal law, drug manufacturers who want their medications covered by Medicaid must rebate a portion of the payments for those drugs to federal and state governments.

Every year, drug manufacturers pay the state $1.5 billion in prescription drug rebates, plus another $138 million in supplemental rebates. In fact, Texas leads the nation in the percentage of rebates negotiated with manufacturers. Under the health plans’ proposal, Texas taxpayers run the risk of losing a major portion of those rebates, which contribute significantly to the state budget and help pay for programs and services for all taxpayers.

The bottom line is, doctors — not managed care companies — should decide what drugs their patients take.

Neither Texans nor the state would benefit from forcing patients to try medications and “fail” before eventually getting the medicine prescribed by their doctors. The Texas Legislature has wisely rejected such a scheme in the past, and our state legislators should reject it again when they convene in January.   

Greg Hansch, LMSW, NAMI Texas

Greg Hansch is public policy director for the Texas affiliate of the National Alliance on Mental Illness, NAMI Texas. He is a Licensed Masters-Level Social Worker and the family member of a person with a serious mental illness.

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