One place to improve government efficiency: Pharmacy benefits

Gov. Dannel Malloy campaigned on a pledge to make government smarter and more efficient, and he is generally making good on that promise.   One area where he can demonstrate this is in the streamlining of access to prescription medications under Medicaid and other state medical assistance programs.

There are about 525,000 state residents who receive prescription drugs under one of these programs.  Some of these drugs are quite expensive, and drug companies extensively market to doctors in an attempt to steer them into prescribing those drugs.  So many states, including Connecticut, have adopted Preferred Drug Lists (PDLs) containing drugs considered generally as effective as, but less expensive than, other drugs kept off the list.  Drugs on the list are readily available with just a prescription, while those not on it are only available through prior authorization (PA), to discourage their use.  This system can save money, but, recognizing that, for many individuals, drugs in the same therapeutic class are not interchangeable and could even be dangerous, PA must be allowed.

The scheme sounds good, but it often falls apart: There are multiple insurance lists that doctors must work with, and they are all different and often changing, so doctors routinely write prescriptions for drugs requiring PA without first checking whether they require it.  When the Medicaid or HUSKY patient presents the prescription at the pharmacy, it is electronically denied by the Department of Social Services. The pharmacist may be authorized to provide a temporary supply, but this works only once. Busy pharmacists with customers in line cannot be expected to call the prescriber to explain that no more of the drug will be available unless they  obtain PA, let alone to identify cheaper alternative drugs.

As a result, patients routinely go home with a temporary supply of their medication, not knowing that that no more supplies are available — until they return to the pharmacy and discover they cannot get any more unless they pay full price, which is rarely possible for low-income Medicaid enrollees.  The state’s pharmacy contractor reported that, in a recent 10-month period for the HUSKY program alone, patients were blocked from access to their prescribed medications 5,142 times because the one-time temporary supply had already been provided and there was no follow-up.  The prescriber does not know that the patient cannot get any more of the drug prescribed, unless and until the patient contacts the office after the denial– which often doesn’t happen.   Eventually, the doctor may learn of this and then scramble to obtain PA for the originally prescribed drug.

What’s wrong with this picture?  Three things: (1) patients go days or weeks without access to any medication for their medical condition; (2)  sometimes this means patients end up in ERs or even in-patient because they could not get timely access to critically-needed drugs, resulting in hospital care costing many times what the drug would have cost (last week a Medicaid enrollee was denied  an antibiotic due to lack of PA, directly resulting in her hospitalization at state expense) ; (3) when the prescriber finally hears about the problem, they generally obtain PA for the originally prescribed drug and don’t even consider the cheaper alternatives which might be as effective because no one has educated them about those options.

There is a ready two-step solution to this ongoing problem. First, the state can immediately follow up with the prescribers to let them know when one of their patients got only a temporary supply of a drug, and advise them of the alternative less-expensive drugs which do not require PA . This is already done by DSS for psychiatric medications.  Second, DSS can mail a notice to patients to let them know that they got a temporary supply only and to encourage them to call their doctor’s office about alternatives before the supply runs out (no change in the pharmacies’ computer systems is necessary; notices will be mailed out by DSS based on data already collected by it).

Around the time that the new Administration arrived, the state’s pharmacy director announced a proposal to do both of these things for all prescription drugs denied at the pharmacy for lack of PA, noting that low-income Medicaid enrollees were falling through the cracks and going without their medications.   A bill to accomplish this also was introduced by others (HB 6360).  Unfortunately, in March, the Rell Administration’s holdover DSS Commissioner, since replaced, testified against the bill, undercutting his pharmacy director.

Governor Malloy can reverse course, support the bill, and adopt these common sense reforms to make access to prescribed drugs, and particularly less expensive ones, more efficient, to the benefit of enrollees and taxpayers alike.   The cost of these modest reforms-mostly a 44 cent stamp when a patient has a problem at the pharmacy-will pay for itself many times over as prescribers, informed of their choices, opt for cheaper medications on the PDL rather than go through the PA process, and expensive hospitalizations resulting from lack of timely access to medications are avoided.

Government can be cheaper and smarter.  Here’s a good opportunity to demonstrate it.

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