Fight for Patient Protections Wages On

Even though the 2012-13 budget was finalized at the end of March, both the NYS Assembly and Senate are still fighting for patient access in Medicaid.  Each house has taken different approaches to allow prescribers to have the final say on patients’ drug regimens and to standardize the prior authorization process.  You can access these bills A.10248, A.10249, S.7384 and S.7325 here:

The introduction of bills to restore prescriber prevails in Medicaid stem from the outpouring of advocacy support during this year’s budget season.  The final budget does allow prescribers to have the final word but only on atypical antipsychotics.  Persons in need of prescriptions from other drug classes are still forced to receive what is determined by their managed care plan.

The Senate bill is simple – it allows prescribers to prevail for all drug classes.  The Assembly approach is more nuanced.  It does allow prescribers to prevail for all drug classes.  It removes prior authorization for previously carved-out classes of drugs, i.e., atypical antipsychotics, anti-retrovirals and anti-rejection drugs and for any other class of drugs to treat mental illness and HIV/AIDS with approval from the DOH Commissioner.  The Assembly provides timeframes for honoring prior authorization requests.  It requires that additions to the Preferred Drug List consider safety, efficacy and patient outcomes, as well as cost – but only as a secondary consideration.

Non-standardized prior authorization is not only a tremendous burden on prescribers, it affects patient access by creating yet another barrier to proper prescribing.  A busy practitioner is going to think twice before plunging into the maze of formularies and rules that accompany the current Medicaid program.  A familiar, one-size fits all process that applies across all plans will help to ensure that patients are prescribed the drug that best suits their particular condition.

The key differences between the Senate and Assembly approach is that the Assembly bill will apply to commercial health plans in addition to Medicaid and prescribers will have the option of using the standard form unless mandated to do so by insurers.  The Assembly also includes a time frame for determinations, with violations resulting in automatic approval.  The Senate version simply calls for a standard form to be used by all Medicaid managed care providers.

It may seem unconventional to try and enact changes to the Medicaid program outside of the budget process, but we’re hopeful that advocates will push on and maintain the momentum achieved prior to April 1.  We have long-time champions on our side in Senator Kemp Hannon, Assemblyman Peter Rivera and Assemblyman Dick Gottfried.  Changes are not out of the question, particularly if both houses can agree to a unified approach.  Success can come with doggedness and flexibility.  Press on! Click here to see what you can do to help us with this important effort.

-Jaime Venditti, 5/29/12