Health Association in New York State, Inc.
Friday Fax from Albany
Resisting Restrictions: Although rebuked by the state legislature last year, the New York State Department of Health continues to pursue the creation of a Pharmacy and Therapeutics (P&T) Committee for the Medicaid program. To jog your memory, a P&T committee is an entity created, under the guise of saving money, with the charge of developing restrictions on access to medications. The effort is an attempt by DOH to save money by forcing individuals with serious health care needs to take cheaper, older, less effective and more side-effects laden medications, rather than the ones their doctors wish to prescribe.
MHANYS is building upon our successful campaign last year, during which we linked with colleague organizations in mental health, physical health and HIV/AIDS to turn back the P&T Committee proposal. The legislature refused to include it in the budget. This year, in addition to continuing our work with last years partners, the campaign is being sponsored by the American Cancer Society, Epilepsy Foundation of Northeastern New York, Cystic Fibrosis Foundations, Arthritis Foundation of Northeastern New York, Alzheimers Association, Cerebral Palsy Associations of New York State, the National Alliance for the Mentally Ill in New York State and the Leukemia and Lymphoma Society.
MHANYS is working through its network of local affiliates to organize the campaign. Forums focusing on educating and organizing the public and ourselves to oppose the committee have been held in Albany, Kingston, New York City and Long Island, with one more on Tuesday in Rochester. Nearly 200 people from across the entire health care spectrum have participated in these forums.
Defeat at the hands of the legislature last year has not deterred DOH, as the agency has now determined that they do not need legislative authority to proceed, and are moving ahead with the plan anyway. DOH expects to have the P&T Committee in place by the end of the month. They appear to have decided that there will be ten members, and most, if not all of them, will either be already under contract or employed, by the state of New York.
Although the P&T Committee has not been finalized, DOH has already restricted access to Zyvox, an antibiotic and Serostem, a growth hormone used to fight wasting syndrome for people living with AIDS. Combining the completely internal nature of the P&T Committee and its membership with the fact that drugs are being restricted even before it is up and running begs the question as to whether the P&T Committee is anything more than a rubber stamp.
In other states, restrictions on access to medications in the Medicaid program have taken several forms. Among them are Prior Authorization and Prior Approval, both of which are already in the pipeline for New York. Prior Authorization already happening here with two drugs, Zyvox, an antibiotic, and Serostim, a growth hormone that fights wasting syndrome in AIDS patients, requires a physician to call a phone number to request authorization for a restricted medication. Presently, no denials are issued, but DOH says that will change in October.
Prior Authorization becomes prior approval when a doctor has to justify the writing of the prescription before it can be issued and filled under Medicaid (A doctor can write a prescription for anything he or she chooses - the question is whether Medicaid will pay for it when the patient gets to the pharmacy). A doctors request for the medication of choice can be denied if the medication is restricted and the doctor has not met the criteria required for prescribing it for this patient. The criteria usually involve using another medication first.
Other types of restrictions implemented in other states include Fail First Policies, Prescribing and Dispensing Limits and Therapeutic Class Substitution. Fail first policies require that a patient fail on older, usually less effective and more side-effects laden drugs before getting the one the doctor wished to prescribe in the first place. For people with serious mental health needs, we believe that this amounts to state sanctioned torture. As pointed out by one of our colleagues, who advocates for care and treatment on behalf of transplant patients, a fail-first policy on medications used to fight the rejection of transplanted organs will likely result in death.
Prescribing and dispensing limits include such novel cost controls as medication holidays in which a months prescription includes a 28 day supply of meds, and the patient gets to take 2 or 3 days each month as a holiday from treatment (nice, huh?) or a limit on the number of prescriptions that can be filled in a month (usually 5). If an individual is receiving a 3 drug HIV cocktail, and a combination of 2 medications for depression, and then gets bronchitis, requiring an antibiotic, which one do they give up to stay within the prescription limit? Or do they simply fail to treat the bronchitis until it becomes pneumonia, requiring emergency hospitalization? And where is the savings in that?
Combined, DOH hopes to save $5 million in prescription drug costs per year, when the P&T Committee, and the restrictions it develops, are fully realized. Studies show that all of those savings will be eaten up many times over in increased health care costs elsewhere in the system, like emergency hospitalization, but in the world of silo budgeting, that $5 million remains crucial.
Or is it? An October 2001 audit by the State Comptrollers office found that DOH has failed to collect nearly $20 million from existing prescription drug savings programs. (New York State Officials) should maximize existing programs to contain the cost of vital prescription drugs before actions are taken which would limit access to these drugs, Comptroller H. Carl McCall concluded.
Our efforts here are a first in one distinct way. In the past, most advocacy efforts have been directed at the legislature or the governor. But, because DOH has chosen to pursue this in secrecy, absent legislative authority, ignoring the rulemaking process, we have no choice but to directly aim our efforts at DOH bureaucratic leadership.
Working with our colleagues, MHANYS has developed a campaign that is moving across the state. Presently, there are about 10,000 postcards in circulation, being distributed through our affiliate network, as well as our colleague organizations and the local campaigns being developed. The postcards are addressed to DOH Commissioner Antonia Novello.
We are also utilizing our internet based advocacy efforts through our website. From there, you can send an e-mail to DOH Deputy Commissioner for Medicaid Management, Kathryn Kuhmerker, and tell her you oppose the P&T Committee and the restrictions to access it will bring.
On our home page, you will see on the right hand side an icon for Oppose P&T Committee. Click on it, and you will bring up the e-mail you can send to Deputy Commissioner Kuhmerker. Add your name and other information at the bottom (only your name is required, but your e-mail address might be good, in case DOH is sending out a response).
Please send your e-mail today! --- Oppose P&T Committee
Legislative Session Takes Convention Hiatus: With the NYS Democratic party holding its convention to choose statewide candidates this week, and the Republican party holding its convention early next week, the state legislature will not be in session until Thursday, May 30th. This leaves a scant three weeks or so to get our legislative agenda completed. Major remaining issues include Reinvestment, Parity, Regulation of ECT and Rockefeller drug law reform.
Since President Bush and Comptroller McCall endorsed mental health and chemical dependency parity over the last few weeks, the State Senate has begun to show some signs of life around the issue.
Of course, the combined advocacy efforts of all of our colleague organizations around this legislation, combined with the very effective cost and polling data may be playing a role in its movement. MHANYS web-based advocacy has resulted in nearly 500 e-mails being sent to legislators in support of mental health and chemical dependency parity.
Our new parity e-mail, added last week, informs state senators that the cost of comprehensive parity is $1.26 per person per month, and that 81% of those polled would be willing to pay it.
If you havent sent out a parity e-mail through our website in the last week, please click on Parity Legislation today!
Additionally, the Assembly is looking to move the package of Electroconvulsive Therapy reform bills introduced by Assemblyman Luster next week. Please call the office of your Assemblymember and urge them to support the bills. Read a copy of MHANYS memo of support.
next time, we remain,