Medicaid Prescription Copay and Restrictions

New update on Medicaid in 50 states as of February 2004

Studies point out some of the good and bad instances regarding prescription interventions. The sad news is that there are very few of these evaluation studies even with extensive searches. Given the ethical and logistic questions, the only real studies have been natural experiment studies such as the New Hampshire and Georgia studies below. Most studies are simple and theoretical with little if any real life experience. No study designed in a more global and detailed fashion has demonstrated safety for patient use. A reasonable summary would be that

1. not enough studies have ever been done to fully examine the impact of co-pay and restrictions

2. some studies do show harm to patients and increased costs. More is possible, but the right studies have not explored these issues. Certain populations such as mentally ill, very poor, multiple illnesses, fare very poorly regarding caps or copays and costs in terms of disability and other health expenditures can easily outweigh benefits.

Studies from managed care and state programs have actually shown increased health costs by restricting drug access (National Mental Health Assoc, MediCal). These include increased costs of prescriptions, more office visits, and increased hospitalizations.

3. certain medications can be bad to restrict, such as drugs for mentally ill patients and possibly others

4. limited studies examining simple measures related to costs can show some benefits

5. more global studies can demonstrate far greater costs in the health sector from prescription situations

California Medicaid study demonstrates increased costs and problems with restrictive prescription policies http://www.pacificresearch.org/pub/act/1998/act_98-06-09.html

6. prescription co-pays and restrictions increase the hassle factors for doctors, pharmacists, and patients and may decrease the perception of quality of care from these groups. Nurses are spending up to an hour a day doing faxes, looking up records, and discussing problems with pharmacists instead of approving a refill.

7. More professional associations are seeing the impact and are sounding the alarm

North Carolina and Florida  http://www.ncpharmacists.org/viewpoints1.html

Pacific Research http://www.pacificresearch.org/pub/act/1998/act_98-06-09.html

8. A focus on drug use and prescriptions can distract from care of patients

A significant drawback of the Medicaid Drug Utilization Review requirement is that it forces a focus on drug use rather than disease state and fosters a tendency toward managing within a drug silo rather than managing care, disease states, and costs.  http://www.ahcpr.gov/news/ulp/pharm/pharm3.htm

9. Cuts in Medicaid can harm state economies through loss of jobs, particularly jobs that provide exits from poverty for the poor. http://www.familiesusa.org/html/medicaid/medicaid.htm