Medicaid's Pharmaceutical Switch Shortchanges Patients

GHLF President Seth Ginsberg Pens Op-Ed

March 29, 2011

NEW YORK — When I was 13 and diagnosed with spondlyoarthropathy, a systemic, degenerative form of arthritis, it was my job to take 12 pills a day to alleviate symptoms. (There is no cure.) It was my mother's job to negotiate with our managed care health insurance company to make sure I got these 12 pills.

When I was 18, I co-founded CreakyJoints.org to provide a social environment for people with arthritis. Today, at 29, along with many of our 44,000 members, I am wondering who will negotiate with managed-care companies when the state's Medicaid program turns over pharmaceutical services for its 4.7 million patients. That's one in four New Yorkers.

Who will negotiate for them? Probably nobody.

Continued ...

Advocacy groups are trying to make this point to legislators; our executive director, Louis Tharp, has met with representatives of Gov. Andrew Cuomo, including Medicaid Director Jason Helgorsen. I am appealing to the governor.

Eighty-six percent of the state's Medicaid patients are already in managed care programs. However, because of a 1998 law, prescriptions are not part of it. They are paid for by the state, and for a good reason that has been lost on Gov. Cuomo's Medicaid Redesign Team, which proposed cost-saving cuts to the state's Medicaid program.

The reason then, and today, is because managed-care companies often put their bureaucrats without medical degrees in between the physician and the patient, denying the drugs a physician prescribes in favor of cheaper drugs that save money in the short-term. This was shortchanging patients and pharmacies, and the Legislature and then-Gov. George Pataki realized it.

I'm not talking about branded drugs being denied in favor of generics. New York Medicaid, since 2002, has had a mandatory generic drug prescribing law, and in virtually all cases when a generic is available, it is prescribed. This helps keep costs down and results in good medical outcomes. But when managed-care companies substitute cheaper drugs, or when a patient is required to fail first on a cheaper drug before getting the drug the doctor prescribed, patients can suffer. Medicaid patients can suffer more because their medical needs are greater.

Sometimes these practices pose a minor inconvenience, but sometimes they result in expensive hospitalizations, serious side effects, and prolonged illness that could have been easily avoided by following doctor's orders instead of the profit motive. In the New York Medicaid world, prescription drugs account for 5 percent of the $54 billion budget. Many branded drugs will be going off patent within three years, further reducing Medicaid drug costs. Nobody knows by how much.

The New York State Department of Health data for 2009, which were used in the Cuomo Medicaid Redesign Team proposal, show that 3.6 percent of the total budget is for branded drugs that are currently protected in one way or another. This means that today a patient gets the drug the physician prescribes, but tomorrow it means the system will be able to deny these drugs, solely for economic reasons.

We'll save a little money and drugs are drugs, right? Of course not. The proposed savings are so small that nobody can accurately say whether any savings will occur, and drugs are not drugs. We are talking about HIV and anti-rejection drugs, anti-psychotics and anti-depressants. Prescribing these is an art. There is no science that says one works better than another. One drug may work for one patient and not for one with the same condition. One drug may keep a patient out of an institution or hospital and productively working, and another won't.

Gov. Cuomo wants to take this 3.6 percent of the budget that is working well for a patient group most in need of programs that work well, and gamble on a managed-care company to save a few pennies on the dollar and not reduce the quality of care or outcomes.

The Medicaid Redesign Team did not include a Medicaid patient, and had only one patient advocate who abstained from voting on the "redesigned plan." The good news, however, is that this is not a partisan issue. The Senate already supports keeping the physician in charge and not letting managed care take over prescription drugs. The Assembly hasn't spoken yet, but many members, including the New York State Assembly Puerto Rican/Hispanic Task Force, have said they are aligned with me, many other advocacy groups, and the Senate. We will soon learn the outcome.

The Senate and Assembly need to isolate Gov. Cuomo and his Medicaid Redesign Team, and stop a profit-driven managed-care contractor from trying to add a nominal 3.6 cents out of every dollar to its bottom line by subtracting it, one pill at a time, from patients it is obligated to serve.

The writer, who was raised in Wesley Hills, New York, is co-founder of CreakyJoints.org, an arthritis social network with 44,000 members and part of the Global Healthy Living Foundation (GHLF), which he also co-founded. The non-profit foundation describes itself as an advocacy organization, based in New York, with the mission to improve the quality of life for people with chronic illness.