Uncertain Access to Needed Drugs: Challenges for Medicaid Beneficiaries Jack Hoadley, Ph.D. Research...
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Transcript of Uncertain Access to Needed Drugs: Challenges for Medicaid Beneficiaries Jack Hoadley, Ph.D. Research...
Uncertain Access to Needed Drugs: Challenges for Medicaid Beneficiaries
Jack Hoadley, Ph.D.
Research Professor
Georgetown Health Policy Institute
July 27, 2007
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Our Study Methods for this Brief
Analysis of benefit offerings and preferred drug lists for reform HMOs serving Broward and Duval Counties.
Eight focus groups were conducted in Broward and Duval counties in summer 2006 and Jan/Feb 2007 with Medicaid beneficiaries
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Who is Affected by the Medicaid Pilots?
Total enrollment as of July 2007 is 175,424 Broward enrollment: 106,448 Duval enrollment: 68,976
84% are children and parents 15% are people with disabilities receiving
SSI but not Medicare
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Other HMOs 5.9%
Pediatric Associates
8.9%
SFCCN 6.3%
Other PSNs 9.6%
Staywell 24.8%
Healthease 13.5%
Amerigroup 10.0%
Humana 9.5%
United Healthcare
5.7%
BuenaVista5.9%
Broward Plan Enrollment, June 2007
Source: July 2007 Florida Medicaid Reform Enrollment Report, AHCA
HMOs
PSNs
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Duval Plan Enrollment, June 2007
United Healthcare
11.2%
Access Health Solutions, 9.3%
Healthease, 51.9%
CMS, 1.8%
Staywell3.8%
Source: July 2007 Florida Medicaid Reform Enrollment Report, AHCA
HMOs
PSNs
Shands/ First Coast
Advantage 21.86%
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Did Reform Plans Use Their Flexibility to Limit Drug Benefits?
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Rules for Benefit Variation
Plans can offer different benefits, allowing consumers to choose.
Can limit drug benefit subject to a sufficiency test. Coverage must meet the needs of 98.5% of beneficiaries. Non-disabled adults: 9 prescriptions per month, or $5,321
annually. Adults with disabilities: 16 prescriptions per month, or
$24,472 annually.
Plans may adopt a preferred drug list. Beneficiaries can obtain drugs not on the list with
prior authorization.
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Drug Benefit Limits, Medicaid Reform HMOs
Broward County: 4 of 9 HMOs (with 50% of reform enrollment) adopted limits.
Duval County: 2 of 3 HMOs (with 15% of reform enrollment) adopted limits.
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Drug Benefit Limits, Medicaid Reform HMOsPlan Broward County Duval County
Amerigroup 9 prescriptions per month
Buena Vista No limit
Humana $5,350 per year
Preferred Medical Plan, Inc. No limit
Total Health Choice No limit
Vista Health Plan of South Florida No limit
United Health Care $5,400 per year $5,400 per year
Wellcare: Health Ease (largest enrollment in Duval)
No limit No limit
Wellcare: Staywell (largest enrollment in Broward)
9 prescriptions per month
9 prescriptions per month
NOTE: For plans with limits, higher limits apply to adults with disabilities.
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Is the Drug Coverage Offered by Reform Plans as Good as That Provided by the State?
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Analytical Approach
50 commonly prescribed drugs. 30 with highest number of prescriptions 30 with highest total costs
Reviewed plan preferred drug lists, compared to state Medicaid drug list.
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Scope of Drug Lists, Medicaid Reform HMOs
Plan Broward Duval50 Top Drugs
Percentage
United HealthCare √ √ 48 96%
Vista (Buena Vista,
Vista Health Plan)√ 45 90%
Humana √ 44 88%
Wellcare (Health Ease and Staywell)
√ √ 41 82%
Total Health Choice √ 39 78%
Amerigroup √ 39 78%
Preferred Medical Plan
√ 37 74%
Florida Medicaid PDL 48 96%
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Drugs Most Often Omitted from Reform Plan Drug Lists
Drug Drug ClassNumber of Plans Not Listing Drug on PDL
Nexium Gastrointestinal 7
Lipitor High Cholesterol 6
Synagis Respiratory syncytial virus 6
Prevacid Gastrointestinal 4
Abilify Antipsychotic 3
Actos Diabetes 3
Geodon Antipsychotic 3
Zocor High Cholesterol 3
Zyprexa Antipsychotic 3
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Can Beneficiaries Get Good Information to Select a Plan That Fits Their Drug Needs?
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How Do Beneficiaries Learn About Drug Coverage?
What they most want to know: Are my particular drugs covered? Information on drug lists not available from
Choice Counselors. Challenging to get information from plans.
In focus groups, beneficiaries had trouble understanding key information. What plan is best for a person who needs a lot of
drugs?
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What Happens When a Beneficiary Looks at Plans?
Eduardo is a Medicaid beneficiary. Takes 6 drugs monthly Wants to choose a reform plan
Assume he finds the drug lists for all plans. Which plan provides the best coverage for his
drugs?
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Eduardo’s Drugs Under Reform
Drug
United Health Care Wellcare Vista Humana
Total Health Choice Amerigroup
Preferred Medical
Plan
Fluoextine √ √ √ √ √ √ QL
Benzotropine √ √ √ √ √ √
Abilify PA √ √
Clonazepam √ √ √ √ √ √ √
Torsemide PA √ √ √
Omeprazole √ √ QL √ √ √ QL
Available, restricted 4 3 3 5 6 5 3
Available, unrestricted 4 3 5 6 6 5 5
NOTE: √ – on the preferred drug list; PA – prior authorization, QL – quantity limit
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Are Beneficiaries Having Problems with Access to
Needed Drugs?
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Focus Group Participants Reported Problems
Problems getting medications after joining a plan or during transition.
Need to get doctor’s appointment quickly to change prescription.
Problems especially a concern for beneficiaries with disabilities.
Doctors may help with requesting exceptions or providing samples
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Physicians Surveyed Also Reported Concerns
As reported in the brief released in May: Benefit limits or formularies often impeded
ability to provide needed treatments. Plans have “very different criteria for prior
authorization of injectible medications” Case manager having “a rough time getting
drugs, therapies, referrals, etc.”
21
Conclusions
Drug benefits for reform HMOs are generally more restrictive than the state benefit. Half of reform HMOs use flexibility to limit drug
benefits. Virtually all HMOs include fewer common drugs
on preferred drug lists than state PDL. Information needed to make an informed
choice of plans is hard to get. Beneficiaries are reporting problems getting
access to drugs.