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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. Our Study Methods for this Brief.
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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
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
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
Broward Plan Enrollment, June 2007 PSNs HMOs Source: July 2007 Florida Medicaid Reform Enrollment Report, AHCA
Duval Plan Enrollment, June 2007 PSNs Shands/ First Coast Advantage 21.86% HMOs Source: July 2007 Florida Medicaid Reform Enrollment Report, AHCA
Did Reform Plans Use Their Flexibility to Limit Drug Benefits?
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.
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.
Drug Benefit Limits, Medicaid Reform HMOs NOTE: For plans with limits, higher limits apply to adults with disabilities.
Is the Drug Coverage Offered by Reform Plans as Good as That Provided by the State?
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.
Can Beneficiaries Get Good Information to Select a Plan That Fits Their Drug Needs?
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?
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?
Eduardo’s Drugs Under Reform NOTE: √ – on the preferred drug list; PA – prior authorization, QL – quantity limit
Are Beneficiaries Having Problems with Access to Needed Drugs?
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
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.”
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.