As a solo family medicine doctor in a rural Texas practice with a moderate-sized Medicaid patient population, and as a chairman of the Drug Utilization Review (DUR) Board of the state’s Medicaid Vendor Drug Program, I must accept the decisions made about what is on the formulary — what drugs are covered — and how those medicines can be used and the hassles associated.
Once again, the Texas Legislature finds itself trying to decide whether the state's Medicaid outpatient pharmacy benefit should remain under the supervision of the state or be carved in to managed care. Currently, 20 managed care organizations provide virtually all services for the state's Medicaid population enrolled in managed care plans. The one exception is the drug benefit, which is run by the Texas Health and Human Services Commission.
With experience treating Medicaid patients and witnessing the impact managed care has had on the quality of care, I have serious concern about moving away from something that has worked so well for patients and providers. Also of important note, the program has saved taxpayers hundreds of millions of dollars over the years. Therefore, the idea that we could see as many as 20 different drug formularies with prior authorization and step-therapy programs — making insurers force patients to try and fail on one or more medications before the medication their doctor originally prescribed will be covered — is both worrisome and problematic. The time and personnel required would become ominous, and would put an unreasonable burden on those trying to service needy patients. At some point, that burden could compromise access to care.
The current Medicaid program provides services for more than four million Texans. Part of the program's responsibility is to provide Medicaid patients with prescription drugs, which efficiently balances cost savings and taxpayer dollars with patient access to needed medications.
Medicaid is very different from the private market: It’s financed differently, the population is diverse, adherence to medications is more difficult to maintain and sometimes, the treatments are different.
Physicians and patients need a transparent process for determining which drugs are covered by the state’s Medicaid Vendor Drug program and ultimately, who is making the decision as to what is best for the patient. The health care community treating patients and the patients affected should be able to provide feedback on why certain medications should be accessible.
What's most important, however, is for patients to get the right medications at the right time. It’s also important to me as a physician. Having consistency in the formulary and in the conditions under which the medicines may be used will expedite the delivery of care for patients, which will diminish the delay of appropriate care. On average, I see 30 or more patients every day. Seeing the same patient multiple times for something that could have been treated correctly in one visit costs both time and money. It's inconvenient and problematic for patients and is certainly not in the best interest of care.
Patients in the Medicaid system have families and are our neighbors. They are often people who contribute significantly to our communities, but don't have the financial resources to obtain other types of medical insurance. Many have jobs without health benefits. While we need to be good stewards of the taxes we pay as citizens of the great state of Texas, access to care should be our priority.
The state has a proven track record of managing an efficient prescription drug program, and has one of the lowest spending on Medicaid net retail drugs. In my opinion, that's reason enough to keep things as they are.