Uncertain Access to Needed Drugs: Challenges for Medicaid Beneficiaries

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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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Broward Plan Enrollment, June 2007
PSNs
HMOs
Source July 2007 Florida Medicaid Reform
Enrollment Report, AHCA
5
Duval Plan Enrollment, June 2007
PSNs
Shands/ First Coast Advantage 21.86
HMOs
Source July 2007 Florida Medicaid Reform
Enrollment Report, AHCA
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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 HMOs
Plan 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 Duval 50 Top Drugs Percentage
United HealthCare v v 48 96
Vista (Buena Vista, Vista Health Plan) v 45 90
Humana v 44 88
Wellcare (Health Ease and Staywell) v v 41 82
Total Health Choice v 39 78
Amerigroup v 39 78
Preferred Medical Plan v 37 74
Florida Medicaid PDL 48 96
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Drugs Most Often Omitted from Reform Plan Drug
Lists
Drug Drug Class Number 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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Eduardos Drugs Under Reform
Drug United Health Care Wellcare Vista Humana Total Health Choice Amerigroup Preferred Medical Plan
Fluoextine v v v v v v QL
Benzotropine v v v v v v
Abilify PA v v
Clonazepam v v v v v v v
Torsemide PA v v v
Omeprazole v v QL v v v QL
Available, restricted 4 3 3 5 6 5 3
Available, unrestricted 4 3 5 6 6 5 5
NOTE v 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 doctors 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.

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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.