To our membership,

Recent changes in Medicaid are beginning to impact some of you. This is a talking point sheet that the National Alliance for the Mentally Ill in Delaware developed to support HB 93 to repeal some of the changes. The bill passed the House, but did not go anywhere in the Senate, so it will come up again next year. The new regs have thing embedded that are not easily understood, including affecting the number of pills you may receive. Note the 5^th dotpoint under the New Regulations section. This is a problem, because children typically get smaller dosages they take over the course of a day, rather than one pill with a bigger dose. For those of you who have Medicaid for yourselves or your children, you need to be familiar with and understand these changes. We need to work together with NAMID and other groups to change this during the next session.                                                                                                                

Delaware Medicaid Prescription Drug Coverage:

Recent Developments Create Potential Risks for Consumers and Physicians

The New Regulations

¨       If a person has more than 15 prescriptions, prior authorization is required for each additional prescription.

¨       Co-pays ranging from $0.50 to $3.00 per prescription.

¨       Preferred Drug List (PDL): only those medications on the list can be prescribed and paid for by Medicaid without prior authorization- typically these are cheaper drugs.

¨       Physicians instructed to prescribe generic or other less-expensive medications- if these are not on the PDL, the patient must fail first on these before getting authorization to receive the PDL drugs.

¨       Physicians urged to prescribe daily doses rather than doses taken throughout the day.

Concerns of Health Advocates & Physicians

¨       Compliance: Medications that are less costly are likely to be less effective, older forms of treatment, or have more or more severe side effects. For people with certain illnesses such as HIV or schizophrenia, the side effects may be perceived as worse than the illness itself, leading to reduced compliance. Additional prescriptions may be necessary to treat side effects.

¨       Affordability: For people whose income is so low that they qualify for Medicaid, co-pays can be prohibitive, especially if multiple prescriptions are needed. If the drugs their doctor believes they need are not authorized by Medicaid, their only likely alternatives will be a less-effective regimen or to forgo particular medications. 

¨       Health risks: Changing medications, requiring a patient to “fail first” on an older medication, and investing authority to decide whether a medication is appropriate for an individual patient in an entity other than the patient’s healthcare provider all put the consumer at risk of worsening their condition. The effects of dosing some medications once a day, rather than spread over a day, may make the patient too ill to engage in or perform well at productive activities such as work or school.

¨       Physicians’ burdens: Prior authorization for multiple prescriptions is a large burden on the time of physicians, especially those who treat many Medicaid clients. If they prescribe a medication that the state will not authorize but the patient cannot afford on their own, that patient will effectively not be treated. If a less effective medication is then prescribed that will be covered, but the patient “fails” on it, the doctor may be at risk of liability for that failure.

¨       Cost savings: The savings that may result from these changes would only reflect savings on prescription drugs. But limited access to appropriate medication is likely to result in increased treatment, hospitalization, emergency department, and corrections costs, as well as reducing the economic productivity of people whose new medications are not effective enough to allow them to work. 

Legislation: HB93

¨       HB93 would repeal those Medicaid regulations which restrict the availability of pharmaceuticals and ensure that such restrictions must be “expressly authorized by the General Assembly”.

¨       The bill passed the House 37-0 on March 22, 2005, and is currently awaiting action in the Senate Health and Social Services Committee. If not passed before the legislative session ends on June 30, 2005, it is unlikely that any action could be taken on the bill before the 2006 legislative session opens on January 10, 2006.  

 

Theda M. Ellis, M.Ed., MBA
Executive Director
Autism Society of Delaware
(302) 472-2638

 

NEWS FLASH! JULY 1, 2005

HS 2 for HB 108 - Delaware Mercury Legislation Passes House and Senate!

Due to the tireless efforts of several ASD members including Jane Miller, Lisa and Joe Dent and Rob Gilsdorf and non members Teri Small and Eileen
Coleman... Delaware now has a law (after the Governor's signature of course!) that will greatly restrict the use of mercury rich vaccines in the
State of Delaware. The group worked with key legislators including, Rep(s) Pam Meier and Dick Cathcart who fought the battle with fierce
determination. The debate was spirited and took place with intensity over the last several weeks and culminated in the final hours of the session
(after midnight last night). On the House floor, our advocates including Pam and Dick as well as Rep Bill Oberle and others worked this important
piece of legislation through the process despite vigorous opposition from the medical lobby in Delaware.

Please read the next addition of "The Sun" for a more detailed account of this significant effort. ASD and its members should be proud of the work
put forth by this group of concerned parents... thinking of others and putting in the time to make the difference. Thanks to all involved who
directly participated and all the others who called their legislators to express their opinion...... we really made a difference!

Regards
Rob Gilsdorf
Chair, ASD Legislative Committee