By Carol Gentry
3/10/2009 © Florida Health News
As a member of the state’s Pharmacy and Therapeutics Committee, psychiatrist Michael Bengtson advises the Florida Medicaid program on which drugs need to be available to patients without a hassle, within the budget available.
But that doesn’t mean the USF faculty member can always get the drugs his own Medicaid patients need. Just before Christmas, he said, he tried to get approval for an antipsychotic drug for a woman who hadn’t responded to a less-expensive version. But her HMO wouldn’t budge, he said, so he had to keep her on the cheaper one.
The state’s drug-approval process is complicated, Bengtson said, especially where managed care is involved. “It’s an area that’s murky to me,” he said.
Several consumer groups agree that it’s murky. They’ve formed the Florida Coalition for Open Access, which they say means “physicians and patients should be able to prescribe and receive needed medications without cash savings being the only consideration.”
One of the coalition’s goals is to educate the public about the importance of the P&T Committee, the panel on which Bengtson is a member. It recommends to the Agency for Health Care Administration which drugs should be on the Medicaid “Preferred Drug List,” which allows doctors to write prescriptions without having to get prior authorization. The committee receives recommendations from an AHCA contractor, Provider Synergies.
The coalition wants to focus light on the decision process at a time of budget constraints, said Scott Barnett, executive director of Mental Health America of Greater Tampa Bay. His organization is playing a lead role because newer psychotropics – medicines to treat schizophrenia and other severe mental illnesses – are costly and may be targeted for removal from the list.
The coalition receives support from two drug companies, Eli Lilly and Janssen but doesn’t endorse any particular drug, Barnett said. “We believe the decision should be between the doctor and patient. The issue is access to proper medications.”
It’s important to remember that the medicines can keep a patient stable enough to function in society, he said. A pricey drug is less expensive than hospitalization, he said.
Barnett said the group wants to work in concert with the P&T Committee and AHCA “to come up with solutions that are best for taking care of patients as well as saving money.”
His group released a “white paper” on Monday summarizing the importance of the Open Access movement. Members include several state mental health advocacy groups and treatment providers, as well as Florida CHAIN, which advocates for the rights of Medicaid patients in general.
The coalition report says medicines should be removed from the Preferred Drug List only when both the budget and patients benefit. Prior authorization “must be fast, efficient, and finally be for the best interest of patients,” the paper says. “It should not be a limit of access to cost-effective therapies for those who need them.”
The group calls for “independent monitoring” of the prior authorization process to assure it is not resulting in inappropriate delays in care.
One of the group’s goals is to require managed-care companies to provide notice to doctors and patients before they change their covered drug list, called the formulary. That would avoid a lot of confusion and wasted time and effort for doctors, the coalition says.
--Contact Carol Gentry by e-mail or at 727-410-3266.