Addressing Medicaid Preferred Drug List Committees

1
Addressing Medicaid Preferred Drug List Committees

• Robert Twillman, PhD
• The University of Kansas Hospital
• Kansas Pain Initiative

2
Background/Introduction

• State Medicaid programs are partially funded by
  the federal government, and partially by the
  state government
• Medicaid expenditures typically represent the
  largest area of expenditure in any states budget
• There is constant pressure to reduce the cost of
  Medicaid

3
Techniques Available to Medicaid for Controlling
Pharmaceutical Costs

• Medicaid programs can control which medications
  are on formulary
• Once formulary is established, programs can
  establish preferred drug lists (PDLs), with
  non-PDL drugs available only with prior approval
• Medicaid programs can require drug companies to
  provide supplemental rebates to have their drugs
  included in the formulary

4
How a PDL Committee Process Works

• PDL Committees typically
• are appointed by the governor or health
  department director, based on authorizing
  legislation
• include physicians from a variety of backgrounds
• May include other prescribers (PAs, ARNPs, etc.)
• Members may or may not be members of the Medicaid
  Drug Utilization Review (DUR) Committee

5
How a PDL Committee Process Works

• Charged with reviewing various drug classes to
  recommend preferred agents within each class
• Based on efficacy, safety, and cost
• Some drug classes are often omitted, especially
  medications for psychiatric conditions
• Consultants are generally hired to review
  available data and/or make recommendations
• Committees typically hold public hearings, at
  which members of the public may testify

6
How a PDL Committee Process Works
Consultants
PDL committee
DUR Board
NOTE Recommendations are not binding at any step
of process
Agency administering Medicaid program
PDL established
7
Testifying at PDL Committee Hearings

• Committees typically will set out rules in
  advance for testimony
• Time and/or number of presenters may be limited,
  and presenters chosen randomly
• Be prepared to present written information you
  may not be chosen to testify
• Remember that PDL committee decisions affect ALL
  pain patients, and are not final decisions

8
Testifying at PDL Committee Hearings

• When testifying, tell the committee you represent
  the state pain initiative and Medicaid
  beneficiaries, not a particular drug or company
• Tell them that you are concerned that adequate
  pain management for beneficiaries with pain would
  be threatened by restricting access to
  appropriate pain medications

9
Testifying at PDL Committee Hearings

• Briefly cite some of the relevant statistics
  related to pain management
• Point out great strides over the past 15 years in
  removing pain management barriers
• Reference steps taken by the state in question,
  such as medical board guidelines, etc.
• Mention that restricting access to medications
  would reverse this trend

10
Testifying at PDL Committee Hearings

• Implementation of a PDL for pain medications will
  be potentially devastating, because Medicaid
  beneficiaries do not have alternatives
• Medicaid beneficiaries are vulnerable because
• They are poor and/or elderly and/or disabled
• They have chronic pain
• They are disproportionately of minority race

11

Testifying at PDL Committee Hearings

• Psychiatric medications are typically excluded
  because they work primarily in the central
  nervous system
• The CNS is complex and not completely understood
• Medications that work in the CNS are less
  predictable in their results (positive and
  negative)
• As a result, prescribers of CNS drugs make their
  best judgment about which medication is the best
• Opioids are CNS drugs

12
Testifying at PDL Committee Hearings

• There is tremendous individual variability in
  positive and negative effects of opioids
• May be due to µ opiate receptor polymorphism
• Maximal effectiveness (reducing costs due to
  repeat physician visits, hospitalizations, use of
  less than a full prescription, etc.), requires
  ready access to all opioids
• Making a choice on cost of the medication alone
  exposes program to cost offsets

13
Testifying at PDL Committee Hearings

• Finally, consider additional burden that will be
  imposed on healthcare providers and patients
• HCPs will have to complete additional paperwork
• There may be a delay of up to 24 hours before
  patient can receive medication
• Some patients with transportation and mobility
  issues have difficulty returning to the pharmacy
• Tell a story about a patient who required
  multiple trials to find the right drug

14
Diversion and Abuse Issues

• The PDL process is designed to control cost, not
  diversion and abuse
• Medicaid already has mechanisms available,
  through retrospective review, to address
  diversion and abuse
• Typically, only long-acting opioids are
  considered for PDLs the most abused prescription
  pain medication (hydrocodone/APAP) is rarely
  restricted

15
Diversion and Abuse Issues

• Because the most prescribed drugs are the most
  abused drugs, a PDL will only shift patterns of
  abuse, not eliminate them
• If 5-15 of the population abuses drugs, then
  using a PDL as a diversion/abuse control strategy
  is establishing a program with an 85-95 false
  positive ratevery inefficient
• Abuse of prescription medications does not imply
  a safety problem

16
Resources

• AACPI websitelinks to state Medicaid program
  websites
• Consultation with AACPI staff and others with
  experience in testifying
• ACS position statement on access limitations