ObamaCare: Will Medicaid Drugs Be Paid?

ObamaCare Word Picture

A little known section of ObamaCare provides that States who use a pharmaceutical managed care benefit for drugs dispensed to Medicaid patients will get a rebate.  Many states are moving toward this approach to save on costs.  Since most states will have a large increase in Medicaid patients, it will be important for you as a healthcare provider to know how these drugs will be dispensed in your state.  The corner drug store may no longer be an option.

“The battle for change now pits pharmaceutical manufacturers, pharmacy benefit managers and both physical and mail-order pharmacies against one another. They are lobbying state legislators around the country to encourage the use of certain medications, incentives and rebates. At the same time, drug costs have increased, and people are using more medications as they develop chronic diseases such as heart disease or diabetes.

One approach is moving to managed care. Managed-care plans mean the state contracts out its pharmaceutical services to a group that agrees to provide services for a lower cost. Rather than a pharmacy charging a set amount every time a person fills a prescription, a managed-care system gets paid more the more money it saves. This can be good for the patient in that there are fewer opportunities for drug duplication. However, there have been concerns that insurers will not pay for medications a doctor prescribes, such as for behavioral health issues, or that quality will be cut along with costs.

Big pharmacy management providers say they can save the states as much as $33 billion over 10 years, according to a 2011 report commissioned by the Pharmaceutical Care Management Association. A new report that assumes Medicaid expansion in all the states because of the Affordable Care Act estimates $90 billion in savings, according to the Lewin Group.”

USA Today, August 11, 2013

We continue to see many changes to managed care type approach to healthcare as ObamaCare is implemented.  All healthcare providers must be monitoring their state.  More patients will have coverage but the coverage will be changing as each state implements its version of ObamaCare.  Providers may need to steer patients to less expensive medications, preferred pharmacies or mail-in pharmacies.

For some specialties, many drugs may have a delay in being approved or simply not be an approved drug.  Behavioral health may be one of these specialties.  This makes patient follow-up care even more important.  Further, many patients lack the ability to order drugs from covered pharmacies and will need assistance in navigating the system.  ObamaCare providers for 1) navigators and 2) in person assisters to choose coverage options in the healthexchange.  However, whether there will also be an ability for these individuals to assist patients with obtaining medicine from a covered pharmacy is unlikely, especially in the short run.  Most of these duties will fall on the healthcare provider as their Medicaid population grows.

Healthcare providers must use all of the available resources to survive in the ever changing healthcare arena.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.