Medicaid Rx Coverage Schemes Threaten Patient Access

January 16, 2018

Cash-strapped states are exploring a controversial new way to cut Medicaid expenses: limiting which drugs their beneficiaries can access.

In Massachusetts, officials requested a waiver from the Centers for Medicare and Medicaid Services to adopt a “widely used commercial tool” – a formulary of approved drugs.  State Secretary of Health and Human Services Marylou Sudders has suggested restricting coverage to one or more drug per therapeutic class and excluding drugs deemed to have limited treatment value.

Some programs across the country are watching to see how the federal government treats Massachusetts’ request. But at least one state is already moving forward with a cost-saving scheme of its own.

Citing a desire to innovate, Arizona submitted a request to the Centers for Medicare and Medicaid Services to “modernize” its prescription drug coverage by excluding breakthrough drugs. Arizona would also like to limit certain drugs it sees as lacking a “significant, clinically meaningful [or] therapeutic advantage.”

Those who recognize that drugs are not one-size-fits-all are rallying in opposition. Dozens of patient advocacy organizations, including the Alliance for Patient Access, have voiced concerns about how these measures could impact patients.

In a letter to CMS, The AIDS Institute described how patients build resistance to certain treatments over time, necessitating periodic drug changes to keep the disease at bay. If only one drug was available and new therapies were prohibited, these patients could face a dangerous shortage of treatment options.

Likewise, the American Cancer Society Cancer Action Network expressed concern about Massachusetts’ desire to exclude innovative drugs that received expedited approval by the Food and Drug Administration. Preventing access to groundbreaking therapies is detrimental to cancer patients, who often have a limited treatment window.

In addition to blocking access to new treatments, restrictions on prescription drug coverage could force some patients to change their current course of treatment.  That might mean destabilizing a patient’s well-managed condition – leading to cascading health problems or even requiring emergency care. That could create downstream expenses that undermine states’ goal to save money.

These factors should weigh into the decisions made by CMS, which must ultimately decide whether doctors or bureaucrats will have the final say in which drugs patients take.

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