Medicaid melee: Initiative has doctors seeing red By SARAH BURGE / H-P Staff Writer | Posted: Saturday, December 21, 2002 12:00 am BENTON HARBOR -- "I'm just in pain so much I can't hardly keep my head straight," said Linda Ward, letting out a long sigh."I have such horrible pain in my legs and sides. Sometimes my right side just gives out and I can't walk."Ward, 52, was diagnosed with diabetes eight years ago. Although she works 25 hours a week as a cleaning person, she still qualifies for Medicaid - the federal/state health plan for the poor.Due to a change in state policy, Ward this year has faced one problem after another getting approval for the multiple drugs she needs to control her diabetes, including expensive pain killers for the nerve damage that has resulted from her condition.For Ward, the additional layers of bureaucracy means prolonged pain and discomfort. For others, the consequences are potentially life-threatening.Best practices?To save money, the state instituted the Michigan Pharmaceutical Best Practices Initiative in February.The plan requires doctors to use a list of state-approved drugs when writing prescriptions for Medicaid patients. If a doctor feels that a drug not on the list is essential, he must get "prior authorization" by demonstrating that the drug is medically necessary.The plan has faced a barrage of criticism from doctors, drug companies and others. A lawsuit claimed the Medicaid drug plan was unconstitutional and endangered the lives of patients.The state Court of Appeals shot down the lawsuit last Monday, so it looks like the plan will stay until the Legislature acts.Michigan is the first state to institute this type of drug plan for Medicaid patients. With the Appeals Court approval, other states may follow suit.State Rep. Charlie LaSata said he wasn't aware of a problem with the prescription drug program. "I have not been receiving calls," said the St. Joseph Republican.La Sata said generic alternatives save the state hundreds of thousands of dollars each week, but he added, "No one should be going without the proper pharmaceuticals."Dr. Don Tynes of InterCare in Benton Harbor said he would challenge LaSata to find a Medicaid patient who will say there isn't a problem. InterCare's doctors see more than 100 patients a week, many are Medicaid beneficiaries.Geralyn Lasher, spokeswoman for the Michigan Department of Community Health, which administers the state Medicaid plan, said the state is spending $1.1 billion per year for pharmaceuticals for 1.6 million people. She said the state is saving $850,000 a week because of the prescription drug program.In the face of statewide budget shortfalls and across-the-board-cuts to publicly funded programs, the case against money-saving measures is a difficult one to make. Lasher said the state simply "cannot sustain" the kind of cost increases it has been experiencing.The state health department insists a significant chunk of the soaring drug costs is the result of unnecessary spending. They claim aggressive drug company advertising campaigns have convinced patients and their doctors that they need new, expensive drugs when older generics would work just as well.Doctors displeasedFrom the state's perspective, the plan does not deny essential drugs, it merely cuts waste, but the doctors treating Medicaid patients couldn't disagree more."They're trying to push drugs that are less efficacious," Tynes said."There are some drugs that are generic, but work," he said. "There are some drugs that are not equivalent. Period."He said there are many drugs that have not made the state list just because the manufacturers didn't give in to pressure from the state to offer discounts.Regardless of program designers' real motives, one of the biggest problems with the new system, doctors said, is that it doesn't work the way the state officials say it should.Lasher calls the prior authorization system "a very quick process." She it takes state call center workers 18 seconds to answer the phone, an average call lasts 1 minute and 40 seconds, and transfers to a pharmacist are completed within 50 seconds.Dr. William Wilkinson of InterCare said the prior authorization system "doesn't work well.""If I were a physician who saw one or two Medicaid patients a week it wouldn't be a problem," he said.Of the Medicaid patients he treats, Wilkinson estimates that 20 percent need prior authorizations for their prescriptions. It's the same story for Tynes, who said the added bureaucracy is just another way to "penalize doctors for taking care of the underinsured."When Wilkinson heard the statistics the Department of Community Health is quoting about the success of the prior authorization system, there was a long pause."Has she tried to get a prior authorization?" he asked.Tynes was not surprised by Lasher's claim."They're totally oblivious to what's really happening," he said.The doctors and nurses said most prior authorization calls take a minimum of 15 to 20 minutes and involve being put on hold and bounced from person to person.Debra Buntin, an InterCare nurse, said, "I've been put on hold before, gone in and talked to two patients and I'm still on hold when I get back. Whenever I call for a pre-auth, I always find some other work to do, because I know I'm going to be on the phone for a while."The nurses said state workers will tell them to wait a couple of hours before calling a prescription in to the pharmacy. They said they'll wait two hours and it still gets rejected. Then they have to go through the whole process again.They never talk to the same person twice, the nurses said, and the sheer amount of telephone numbers for each drug class makes the process even more complicated.With antidepressants, for example, the nurses don't even have the option of calling for a prior authorization. They have to send faxes that frequently go without a response until the next day.Drawing out the process, doctors said, has much the same effect as denying authorization because patients end up paying for the prescriptions out of their own pockets or, worse yet, going without medication.Sample therapyNalter Christian of Benton Harbor said she has problems getting prescriptions approved for her son, who has severe mental problems, including hallucinations."I had to do something this time. I bought two pills for him," she said. "I can't afford more."InterCare's Dr. Wilkinson said he had one patient who had been hospitalized with a stomach problem. He said a specialist sent her home with a prescription, not knowing the drug wasn't on the Medicaid list, and the patient couldn't get her prescription filled."That happened during a weekend," he said. "She went three days without her medication. Can you imagine coming home from the hospital and not being able to get your medication?"Wilkinson said he gave her samples as soon as she came to see him, but in the end Medicaid didn't approve the prescription."She has to use a medicine I know won't work," Wilkinson said. "She has to use it and fail" before Medicaid will approve the original prescription.And with her condition, he said, "There's a very high risk for going back in the hospital."The same thing happened to Lois Clay, who was hospitalized with a heart infection. She also went three days without her medication while waiting for an approval."What I don't understand," Clay said, "is why they needed authorization for my medication. Evidently the doctor thought I needed it, otherwise why would he have prescribed it?"Tynes and Wilkinson have both seen numerous cases like these."The sample closet is how we're keeping patients alive," Tynes said. "We finally got people to learn to take their medication, but now they can't get it."The doctors said Medicaid frequently changes the list of approved drugs without warning. Sometimes they don't know a drug is no longer on the list until a prescription gets rejected.Wilkinson said they don't have master lists of which patients are on a particular medication, so they don't know who will be affected. Beyond that, many of their patients have such hectic lives that the doctors are unable to contact them.If a drug is taken off the list, the patients don't know until they visit the office or try to refill their prescription.Wilkinson said it's not unusual for patients to go without their medication for months because Medicaid refuses to cover their prescriptions when they try to get a refill. Rather than go to the trouble of contacting their doctor, they just stop taking the medication.Doctor's dutyThe state health department's Lasher called the doctors' claims "ludicrous."They can make claims, but the facts don't support them."Lasher said the health care industry has relentlessly tried to discredit the program which, she said, "has worked very effectively."It's frustrating that they have continually misrepresented this program."If you have health care, you have a prior authorization program. This happens every day."She said Michigan is not required to have a pharmaceutical benefit program of any kind for Medicaid patients."We spend $1.1 billion," she said. "It's not as if we aren't spending enough on pharmaceuticals."Lasher said if patients are going without necessary drugs, "Then the doctors are not doing their jobs."But, doctors say, if anyone is to blame it's Medicaid.Referring to the drug plan, Wilkinson said, "It makes it very difficult to practice. Sometimes it feels like we're practicing with one arm tied behind our backs."Wilkinson said a patient could take him to court for some of the compromises the Medicaid drug plan forces him to make. Wilkinson said he has to prescribe drugs that he knows are not the correct, or at least, the most effective choice.Tynes said the plan is "playing with the drugs."He said it forces doctors to "take a gamble."This is not business. 'Loss' in medicine means death or injury."Tynes and Wilkinson don't agree with Lasher's claim that the Medicaid drug program is comparable to that of private insurers. They said Medicaid's drug list is more restrictive and the authorization procedure is more cumbersome.Tough choicesBy creating a prescription drug program like this one, the doctors said, the state can achieve the cuts it needs, while avoiding politically unpopular choices - such as telling low-income people they will have to make do with second-rate medications.Instead, the state has passed the buck to doctors. If a patient doesn't get the proper medication, they argue, then the doctor hasn't done his job.By placing the burden on doctors, Wilkinson said, "that's what is going to drive doctors out of the Medicaid system."Doctors already complain that treating Medicaid patients is a losing proposition, arguing that Medicaid compensation doesn't cover their costs. Wilkinson said doctors accept Medicaid patients "out of the goodness of their hearts.""If this continues to escalate," Wilkinson said, "there's not going to be anyone willing to take Medicaid patients. It's fraught with hassles."With the swelling numbers of Medicaid beneficiaries, the increasing drug costs and a sluggish economy, the state has no choice but to make cost-cutting measures, but Wilkinson said the state needs to "define what Medicaid is going to be."The system is imbalanced. There's a desire to have Cadillac care at Yugo prices. You can pour money in, cut waste, limit access. … In this case, they're limiting access."Wilkinson said if Medicaid officials want to control prescription drug costs, they need to come right out and say, "We are not going to be state-of-the-art health care. It's going to be parachute coverage."He said that probably "won't be palatable to many people," but it's what they have to do if they want to keep doctors in the system."There's not anything coming out that's inexpensive," he said. "The new advances in medicine have a price tag."Pill countersA St. Joseph pharmacist who didn't want his name used because of his employer's media policy said, "(The state is) trying to save money, but whoever's making the decisions isn't following through to make sure they're effective."I applaud them in trying to cut costs, but, like Clinton with national health care, it's so complicated that they end up doing nothing. The system is so complicated that even the people running it don't know the ins and outs."There are probably good people trying to make it work, but it's too complicated to make it work."The people making the decisions are "pill counters - I mean bean counters," he said, correcting himself. "The doctors aren't used to being told what to use. Doctors aren't bean counters. They're in the people business."But the pharmacist was right to call them "pill counters."The stakes of cutting health care costs are not the same as cutting regular business costs. The difference between bean counting and pill counting, as Dr. Tynes put it, is that pill counters make decisions that "can be life-sparing or life-taking."

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