Friday, April 22, 2016
By Sindi J. Rosales and Donna Stahlhut
The Texas Legislature is considering a changes to the state’s Medicaid program that could jeopardize access to care by allowing insurers, not physicians, to choose which medications managed care plans would cover.
Drug formulary changes, intended to cut costs, often translate into medical complications that hurt the vulnerable beneficiaries served by the Medicaid program and are far more costly to the state in the long run. Take for example the changes proposed to the formulary for epilepsy medications. Research shows that access to epilepsy medications leads to greater seizure increase control and fewer hospitalizations — and that savings from restrictive formularies often lead to greater spending on medical complications that outweigh those savings.
Epilepsy medications are not interchangeable, and individuals often react quite differently to available treatments. With each medication come side effects, often significant enough that quality of life is compromised and many patients abandon their treatment. This is why people living with epilepsy need meaningful access to the full range of treatments available — and the specialists who know how to prescribe them.
Selecting the appropriate epilepsy medication to achieve seizure control requires consideration of a number of variables, including type and frequency of seizures, age, gender and health conditions. It also often requires trial and error, along with close observation of blood levels and side effects. Preserving open access to epilepsy medications in the Medicaid program ensures meaningful and timely access to epilepsy care.
The human toll of uncontrolled seizures is significant and extends beyond the individual living with epilepsy. Delaying access to medications and interrupting proven treatment regimens leads to breakthrough seizures, related complications, and increased medical costs due to preventable seizures, including accidents, emergency room visits, and hospitalizations. Along with a decreased quality of life and costly health complications, there’s also the lost wages and productivity for individuals living with epilepsy, their families, and their communities.
Prescription drug costs for the Texas Medicaid program are within the national average. The majority of the prescriptions are for generic formulations. Restrictive formularies that promise additional savings at the expense of access to physician-directed care for people living with complex chronic conditions would harm the program’s most-vulnerable beneficiaries and lead to medical complications that will cost the state more in the long run. Formularies that ensure access to a wide range of medications for the vulnerable populations served by the Medicaid program, who often live with multiple and complex chronic conditions, would achieve greater savings in the long run while protecting patient and public safety.
For many years the Epilepsy Foundations of Texas has led the fight for greater access to care for the 461,000 Texans living with epilepsy and seizures. Time and again Texas has recognized the importance of quality epilepsy care by preserving open access to epilepsy medications in the Medicaid program. The Medicaid program in Texas is not alone. Many states and the federal government offer similar protections for epilepsy medications by placing them in a protected class in state Medicaid programs as well as in Medicare.
As the House Human Services Committee debates whether to allow managed care companies to create their own formularies, we urge them to consider the negative impact that moving away from the current single formulary would have on the people served by the Medicaid program. Living with epilepsy is challenging, but timely access to the right medications results in seizure control for the majority of people living with epilepsy. Preserving the current single formulary and the protections for medications for the most vulnerable beneficiaries – which ensure physicians, not insurers, make medication decisions — would lead to a better quality of life and savings to the state in the long run.
Rosales is the chief executive officer for the Epilepsy Foundation Central & South Texas. Stahlhut is the chief executive officer for the Epilepsy Foundation Texas of Houston/Dallas-Fort Worth/West Texas.