Medicaid, budgets and patients: What must be done

As states transition or consider transitioning the Medicaid pharmacy benefit over to a managed care system, policymakers and regulators must ensure the program has protections in place for patients in need.

Editor’s note: Last week, we ran a four-part series on proposals in several states that would change the way they administer the pharmacy benefit in their Medicaid programs – transitioning from traditional fee-for-service Medicaid to a managed care model. Here is the full series in one story.

At a time when all levels of government – from cities and towns to states to the federal government – are taking a hard look at their finances, many states are seeking to find savings in their public health programs.

Some states – including New York, Kentucky, Texas and Ohio – are looking to reduce costs by considering moving their Medicaid pharmacy benefit from a fee-for-service model to a managed care system.

At its essence, this means these states would no longer pay for health care services separately for individual patients – and instead would impose a cap on total spending for patients that is below the fee-for-service model.

As John Iglehart of Health Affairs recently noted:

(The) most transformative change that states are embarking on is contracting with private managed care plans to provide care for more beneficiaries – especially the most expensive ones, the aged and disabled. And although the evidence suggests that states are in fact likely to achieve billions of dollars in savings through these arrangements, the impact on beneficiaries’ quality of care or their health outcomes is a major unknown.

What is AstraZeneca’s view of these potential changes?

In this extended blog post, we’ll be taking a look at different aspects of the proposals at the state level – most notably:

  • Under this model, who is making the decisions for patient care?
  • Do these changes put at-risk patients in greater jeopardy?
  • What kind of patient protections should be included in any Medicaid model?

Finally, here are some definitions of the programs we will be discussing in the posts:

Medicaid is a public health insurance program run by the states in partnership with the federal government. It is available to low-income residents who do not have private health insurance and meet certain eligibility requirements, which vary by state. More information is available at the Centers for Medicare and Medicaid Services website here.

Fee for service is the traditional Medicaid program in which health care providers are reimbursed for the individual services they provide. The state of Indiana provides useful information on the program here.

As noted above, Medicaid managed care plans provide set dollar benefit amounts for all services per patient – rather than reimbursing for individual services under the traditional fee-for-service Medicaid program. Read more here.

Doctors Know Best

Doctors know best what treatment options their patients need.

As we noted above, Health Affairs raised the question of what the Medicaid managed care model would mean for patient care.

One of the biggest reasons for this question is that changing to a managed care model could limit treatment options that doctors may consider when deciding how to treat Medicaid patients. This is because of caps imposed on the number or variety of services and/or treatments doctors may consider when treating these patients.

AstraZeneca believes that as any state considers a change to Medicaid, patients under managed care programs should have the same rights and protections they currently enjoy under traditional fee-for-service Medicaid.

Without these protections, the government becomes a barrier between patients and their doctors. Medicaid patients being shifted to managed care programs should receive at least the same coverage of and access to their medicines as they previously received under fee for service.

Why?

Doctors are best qualified to determine the best treatment for an individual, and a one-size-fits-all formula doesn’t work when determining the best care.

These decisions should be based on medical history, family history, drug interactions and other factors that doctors use in concert to prescribe the right treatment for patients.

Doctors carefully evaluate many factors when deciding on treatment for a patient and combine specific patient information with their medical training and judgment to prescribe the best medicine for individual patients.

Patients and doctors often work together for a long time to find the best medicine for the individual patient.

That progress cannot be lost and the patient should not be forced to endure a new medicine based on a government rule or guideline.

Patients at Risk

Medicaid is an essential program for millions of Americans who do not have private health insurance.

How essential? Consider a study of the Oregon Medicaid program that found:

  • One year after the enrollment, those receiving Medicaid benefits reported they had received 30 percent more hospital care than their uninsured counterparts, in addition to 35 percent more outpatient care and 15 percent more prescription drug care.
  • Medicaid patients were 70 percent more likely to find a regular doctor.
  • Insurance coverage decreased the probability of having a bill sent to a collection agency by 25 percent, out-of-pocket medical expenses by 35 percent and the need to borrow money or skip other bills by 40 percent.

Given the importance of Medicaid to these patients, they should have the same medical options available as elected officials and other public employees – and decisions about their care should be left to their doctors, as we noted above. Otherwise, those at risk will suffer most.

In many cases, doctors may not have full treatment options for vulnerable patients if states substitute government’s medical judgment for that of medical professionals.

Without patient protections, a patient’s choice will be to either use a medicine that the doctor and patient already know is ineffective – or submit confusing paperwork and wade through a bureaucratic government process to get the care that their physician recommends.

Doctors must be allowed to give the care that they judge to be most effective.  Including patient protections in managed care Medicaid plans is a simple step to protect patient health while saving money and time for all involved.

Patient Protections

As states transition or consider transitioning the Medicaid pharmacy benefit over to a managed care system, policymakers and regulators must ensure the new program has the same protections in place for patients in need.

Fee-for-service Medicaid patient protections provide a clear example of the types of pro-patient policies that should also be included in a managed care Medicaid system

What kind? Fee-for-service Medicaid patient protections provide a clear example of the types of pro-patient policies that should also be included in a managed care Medicaid system.

These established policies provide an accepted standard of patient protection in the Medicaid system and are a road map to preserving good patient care.

The following standards must be adopted from fee for service to managed care:

Continuity of Care  – If a patient is already being effectively treated with a specific medicine, they should not have to change medicines as a result of the state’s Medicaid policy.  Often patients and doctors work together for a long time to find the best medicine for the individual patient.  That progress cannot be lost and the patient should not be forced to endure a new medicine based on a government rule or guideline.

Prescriber Choice – A system must be included in managed care Medicaid plans that allows the expert opinion of a trained medical professional as to the best care for the patient to supersede the bureaucratic recommendation.  This is paramount to good healthcare and the safety of the patient.

Public Input – The formulary for managed care Medicaid should be arrived at in a transparent way, creating an opportunity for the interested, knowledgeable public to have their input included.  Patient advocates and healthcare providers have expertise, knowledge and experience that are indispensable when arriving at the best policies to provide healthcare to Medicaid patients.

Taken together, these protections will ensure patients will receive the care they need through the Medicaid program.