Managed Care Scrutiny & Safeguards for States Critical, Too
Background: Medicaid beneficiaries are in "significantly worse health" and necessitate more care from pharmacists than other patients. Prescription drug coverage for these patients should never be considered an optional benefit.
Community pharmacists achieve lower Medicaid costs and safe, effective medication use. Up to $290 billion is spent annually due to improper use. Face-to-face consultations with pharmacists reduce hospitalizations, emergency room visits and other costly interventions.
The #1 predictor of medication "adherence" is patients' personal connection with their pharmacist or pharmacy staff. That's highest among those who use independent pharmacies. Formalized pharmacist counseling, such as medication synchronization or medication therapy management (MTM), can improve patient care and cost savings for the state.
Lower-cost generic drugs are promoted by community pharmacists. Their generic recommendations are accepted 95 percent of the time by physicians.
Greater utilization of pharmacists in health care delivery is recommended by the National Governors Association and federal Center for Medicaid and CHIP Services.
A critical access point in underserved urban and rural areas, 17 percent of independent pharmacy prescription volume is tied to Medicaid – a much higher share than national chains.
Medicaid reforms must feature strong patient and taxpayer protections.
Reasonable pharmacy reimbursement that accounts for drug product costs, dispensing costs, prompt payment and real-time adjustments to reflect price spikes.
Patient choice among a robust pharmacy network.
"Any willing provider" language to protect vulnerable patients from restrictive networks.
State oversight and transparency into managed care organizations (MCOs), including PBMs.
Federal false claims against Medicaid MCOs have been settled in recent years in Florida ($137.5 million), Ohio ($26 million) and New York ($46 million). In other states, including Connecticut, Kentucky and Missouri, there have been questions about Medicaid managed care.