Medicaid is changing its rules to steer doctors away from prescribing the most expensive drugs when cheaper substitutes are available and from improperly prescribing OxyContin, a pain-killer that’s sometimes diverted for recreational street use.
The revised rules were announced to patients and medical providers in letters sent last week. Beginning in January, more drugs will require “prior authorization,” a requirement that prescriptions be individually approved by the state before being dispensed.
By making it more difficult to prescribe the most expensive brand name drugs the state hopes to save $3.1 million in the first year and $3.6 million in the second year. Those savings will be on an annual drug tab that is about $200 million now, said David Winslow, a spokesman for the Department of Human Services.
Because pharmaceutical expenses are now so high, the state can no longer ignore the opportunity “to promote clinically appropriate drug utilization practices,” Christine Gee, pharmacy program director for the Bureau of Medical Services wrote in a letter to providers.
“The overriding issue here is the state is having budgetary concerns,” said James Raczek, vice president of the medical staff at Eastern Maine Medical Center in Bangor and an adviser to the state on the latest revisions. “They have to get money out of some of the programs.”
Raczek, who is also administrator of EMMC’s pharmacy service, said simply directing doctors to one drug over another can net 50 percent in savings. Doctors often don’t know where those savings are because one drug can have so many different prices under different insurance and state program contracts, Raczek said. While he called the changes “reasonable,” Raczek said a few doctors will complain that the program increases administrative burdens.
Under the new rules, only a 34 day supply of brand-name drugs can be prescribed while generics can be prescribed for 90 days. Some drugs that typically become ineffective the longer they are used will have supply limitations to prevent medication being prescribed that ultimately remains unused. Maximum monthly dosages are set for some drugs and a number of cost-effective drugs purchasable over-the-counter can be bought under the program without prior authorization.
Prior authorization has been in the news lately. In October a federal court judge issued an injunction against DHS preventing it from using prior authorization in the Medicaid program as a tool to pharmaceutical companies to negotiate lower drug prices for a separate program covering the uninsured.
Generic drugs by some manufacturers are included on the new list of medications requiring prior authorization. Raczek said in some cases generics can be priced high in contrast with the majority of generics.
In its letters, the state assured Medicaid patients that even though they might face a delay in getting a particular drug, doctors would have samples ready to tide them over.
The changes don’t sit well with some.
“It’s the biggest piece of garbage that’s ever come out of the Department of Human Services,” Donald DeGolyer, owner of Lubec Apothecary said.
He said the prior authorization rules would be trying for doctors who have small practices and aren’t familiar with the administrative time necessary to comply with the new rules.
Because the few drugs that are already on the prior authorization list take as long as three weeks to gain approval, DeGolyer said he wonders how long patients would have to wait once a new blizzard of prior authorization paperwork begins arriving in Augusta.
DHS’ Winslow said the typical prior authorization takes far less time than that. Under the new rules, the state has plans to complete each decision in 72 hours or less.
In the pages of rules on drugs are a number of revisions for the prescription of OxyContin. No prior authorization will be needed for any cancer patient’s prescription. For other patients, however, doctors must show documented use of two alternative long-acting narcotics, from among five alternatives including morphine sulfate, before prescribing OxyContin.
In addition, some patients on high doses may be required to get a single daily dose under the supervision of a physician.
DeGolyer applauded these changes. He said OxyContin commands such high prices on the street that prescribing and patient abuses are out of control. More documentation will help in this area, he said.
Raczek said OxyContin prescriptions have skyrocketed. Possible reasons include the effectiveness of the painkiller, the effectiveness of the marketing campaign for the drug, patients who prefer OxyContin, and cynically, the value of the drug if diverted. While it would be nice if every doctor were meticulous in prescribing the drug, that’s not universally true, Raczek said.
“This forces the physician to think about ‘OK, is OxyContin really the medication I want to prescribe to the patient.”‘