Magazine article Drug Topics

Proceed with Caution

Magazine article Drug Topics

Proceed with Caution

Article excerpt

Health maintenance organizations (HMOs) may well want to take a deep breath before plunging into the Medicaid marketplace. At least on the pharmacy side, new pressures rise quickly.

Consider, for instance, that Medicaid patients in Philadelphia can change health plans every month if they so desire-unlike commercial patients, who are typically locked into a plan for a year. It's not easy to consistently manage such patients' pharmacy care, and that was one of the dilemmas described by Joseph Mack Jr., director of pharmacy and therapeutics at Health Partners, an HMO in Philadelphia. Speaking at the Academy of Managed Care Pharmacy's (AMCP) conference on Medicare and Medicaid, held at the end of January in Baltimore, Mack told an audience of 200 attendees of the challenges his HMO faces in serving the pharmacy needs of Medicaid enrollees.

Health Partners is a nonprofit, voluntary, Medicaid HMO that has 86,500 enrollees who are Medicaid recipients, he explained. Because the HMO provides care for all these patients on a capitated basis, costs are under close scrutiny-including pharmacy expenditures.

While commercial enrollees help defray pharmacy costs through a deductible plus a co-pay, Medicaid enrollees are subject to neither, he said. Also, because the state insists on an open formulary, all drug claims must be honored. Health Partners can require prior authorization for some drugs, he said, but there must be a strong, defendable rationale for the requirement. …

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