WASHINGTON _ A study of how the Tennessee managed careprograms limit the utilization of prescription drugs to Medicaidrecipients suggests that new biotech therapies will encounterdifficulties being accepted into use by managed care plans.
The study, Effects of Prescription Drug Access Restrictions onMedical Practice and Patient Outcomes, was funded by Pfizer Inc., ofNew York, and performed by Yankelovich Partners Inc., a Norwalk,Conn., consulting firm.
The study surveyed about 200 Tennessee physicians who reportedthat TennCare, Tennessee's managed care program for the poor,prevented them from treating their patients effectively because ofrestrictive drug formularies. The physicians also said many of theirpatients had serious adverse reactions or complications because ofthe lack of access to the prescription recommended by the physician.
Because of uncontrolled Medicaid expenditures in recent years, manystates have turned to managed care as a way to control spending andin some limited cases expand access. Converting Medicaid'sfinancing program from fee-for-service to managed care requires awaiver from the Health Care Financing Administration, the federalagency administering the Medicare and Medicaid programs. To date,12 states have been granted waivers to shift their Medicaid recipientsinto managed care plans.
Both the Clinton administration and top Republicans in Congress areinterested in giving states even more flexibility in redesigning theirMedicaid financing and benefits packages to control expenditures.Many health care practitioners and drug companies are worried thatstates may elect to exclude expensive therapies from their formularieslists regardless if the drug is cost effective.
"We are concerned that as states struggle to provide coverage undermanaged care expensive drugs will be easy to exclude," said CarolSardinha, a spokeswoman for the Academy of Managed CarePharmacy, a professional society for managed care pharmacists inAlexandria, Va.
"The upshot will be to drive up costs long-term if patients are notproperly medicated and develop complications and must behospitalized to stabilize them," she said.
"The appropriate prescription is a key element in quality health care.Just to hand a patient the cheapest drug is not managed care,"Sardinha added.
The study's findings are particularly troubling for biotech companies,said Bill Aliski, vice president for reimbursement for Cambridge,Mass.-based Genzyme Inc.
"For biotech firms that market a drug such as Ceredase that isindicated for a small population of people, it would be easy for a statemanaged care drug formulary to think they are saving money bydenying coverage," Aliski said. "People with rare diseases then endup being denied access."
Even biotech drugs that are aimed at diseases that are more prevalentwill encounter serious hurdles to the marketplace. "A new technologyor biotech drug may be viewed by a state Medicaid plan as anopportunity to reduce costs. Biotech drug firms will have toovercome this preconception," Aliski said.
However, he added that drugs aimed at a larger population tend to beless expensive, so that "means they will not hit a Medicaid plan'sradar screens with the same impact as a drug that costs $25,000 ayear."
"The end result may be that lower income people as a group may bedenied access to new technologies," Aliski said. He recommendedthat as it considers Medicaid reform, Congress "needs to take intoaccount how to continue access to important medical advances at thesame time fiscal responsibility is maintained." n
-- Michele L. Robinson Washington Editor
(c) 1997 American Health Consultants. All rights reserved.