March 27, 2006

HEALTH SUB-COMMITTEE CLOSES DOWN: After a weekend filled with negotiations between the Assembly and Senate regarding issues related to the health and general government/local assistance, the sub-committee on health met on Sunday evening at 6:00 to finalize the issues remaining at the table, and both committees reported to the General Conference Committee ('mothership') at 7:30 later in the evening. With the exception of issues related to the future conversion of public health insurance plans to private entities and how to create a new state Medicaid Inspector General's office to address fraud in the Medicaid system, the health sub-committee came to an agreement on the remainder of the issues at their table. In total, the additions agreed to between the Assembly and Senate amount to more than $800 M in additional spending above the Governor's proposal.

Related to the issues we have been following, the Health sub-committee agreed to reject the Governor's proposal to both: 1) eliminate the "physician prevailing" language from the Medicaid Preferred Drug List, enacted last year, and 2) include cost as a factor in determining which drugs would be placed on the Medicaid program's Preferred Drug List. These restorations were a major priority to MHANYS and many of our colleagues in mental health advocacy and represent a very positive development in the preservation of access to medically necessary medications for Medicaid recipients.

The other major issue we were following at the Health table related to the extension of a Medicaid "wrap around" for dual eligible individuals who may be experiencing difficulties in accessing prescription medications via their Medicare Part D plan. The sub-committee agreed to the "wrap around" coverage from July 1, 2006, as the Governor's proposal called for, through to January 14, 2007. While we are pleased by this extension, in that it will provide a safety net for dual eligibles having difficulty accessing medications under Part D, there is significant concern about how this will work in relation to revised formularies under Part D plans. While dual eligibles can change Part D plans on a monthly basis, there are likely to be significant changes to the formularies of these plans starting on January 1st of next year, after all other enrolled individuals will have had an opportunity to switch plans (which they can only do during an open enrollment period at the end of each year). Practically, major difficulties could re-emerge during this time after the first of the year.

Lastly, on the sub-committee agreed to further examine "the proposal to eliminate emergency care prior to eligibility confirmation ("Brad H."), which relates to the provision of services to those leaving prisons and jails.

We thank those who contacted their elected representatives on these issues and to those in the Legislature who fought to ensure they remained part of the final negotiation.

 

IN THE NEWS:

Pataki proposal would limit access to certain medications. By Candice Choi
The Ithaca Journal, March 27, 2006

ALBANY — When the state created its “preferred drug list” for the poor, a provision was included to preserve a doctor's authority to prescribe medications not on the list whenever he or she felt it was necessary.

Now Gov. George Pataki is proposing to repeal that clause. If successful, advocacy groups say the state's most vulnerable patients won't have equal access to prescription drugs.

“We're shocked and alarmed that the state is proposing to change this — it was a carefully negotiated consumer protection. Our expectation was that this was an essential part of the program,” said Chuck Bell of the Consumers Union.

The “preferred drug list” was adopted by lawmakers to curb the skyrocketing costs of prescription drugs. To get on the list, drug companies must pay the state large cash rebates. Medicaid will only cover drugs on the list.

The preferred drug list is already expected to save $200 million in its first year of operation by excluding expensive drugs that may have the same benefits as cheaper versions, according to the state Health Department. Pataki says repealing the “physician override” would save another $36 million.

To ensure patients would get the most appropriate drugs, consumer groups lobbied heavily for physicians to retain the authority to prescribe drugs not covered on the list if needed. The legislation passed, with the provision that doctors would be able to get prior authorization from the Health Department to prescribe unlisted medications.

The unspoken understanding was that doctors would never be denied authorization to prescribe unlisted medications, doctors and state officials have said.

“The relationship between the physician and patient is something you never want to mess with,” said Bill Ferris, legislative representative for the AARP. “Certainly the doctor should always have the final say.”

AARP only backed the legislation because the physician override provided the balance of power, he said.

According to a written statement from Pataki's Division of Budget, the proposal to repeal the physician override would enact “needed reforms to control costs” and help combat fraud. Doctors would still be able to prescribe unlisted drugs if they provided the state with “an acceptable clinical rationale,” according to the statement.

The list of drugs would be routinely evaluated by an independent pharmacy and therapeutics committee.

In recent years, many states have enacted preferred drug lists to stabilize spending on prescription drugs.

Between 2002 and 2004, state Medicaid spending on prescription drugs rose at triple the rate of overall Medicaid spending. In the 2002-2003 fiscal year, Medicaid spending on prescription drugs in the state was $3.4 billion; that figure rose to $5 billion in the 2004-2005 fiscal year.

Overall Medicaid spending last year was $44.5 billion.

Since the preferred drug list is just now being implemented, there is no way to tell what problems may surface or how widespread they may be, Bell said. That's what makes the proposal so outrageous, he said.

“Who's in the best position to make decisions for these patients? To erect more administrative hurdles really doesn't make sense,” Bell said.

Having “somebody up in Albany second guessing” those decisions makes no sense, Bell said.

Harvey Rosenthal of the New York Association of Psychiatric Rehabilitation Services, said taking away the physician override would force patients to take drugs that may not be medically suited for them.