D.C.'s Medicaid Rules Criticized

August 8, 2008

District officials are enforcing new guidelines for prescription drugs for thousands of Medicaid patients, leaving many doctors complaining that it is more difficult for sick people to receive some medicines and that some people's health is being endangered.

Three weeks ago, a new pharmacy benefits contractor for the District began requiring many patients to have prescriptions for some pain medication and gastrointestinal drugs preapproved by District Medicaid officials. The result has been delays of several days for some patients to receive medicine, including insulin for diabetics. In one instance, doctors said a diabetic with severe dental problems blacked out and required emergency medical care when he was unable to obtain a prescription for pain medicine that would have allowed him to eat and maintain his proper blood sugar level.

District officials acknowledge that the changes took doctors and patients by surprise but said that they have been trying to work quickly to address concerns.

Rob Maruca, senior deputy director of the D.C. Medical Assistance Administration, which sets the rules, said he wrote all doctors with Medicaid patients in the District yesterday to explain the changes and note several "fail-safe" efforts to address emergencies, including allowing pharmacists to distribute a three-day supply of drugs when a doctor cannot be reached for authorization. Also, he said, emergency room doctors have more leeway in prescribing pain medications.

"We've heard some of these stories" of delays and problems, he said. "As soon as we heard about it, we put fixes in."

But doctors and pharmacists who serve Medicaid patients say the changes are "ridiculous." Doctors said patients are being delayed in many cases from receiving medication that had been prescribed for them for years. The changes affect the more than 50,000 people in the District who receive Medicaid.

"This is completely crazy," said Amy Kossoff, a doctor who works at three homeless shelters and has treated Medicaid patients in the District for more than 15 years. "It just seems a complete waste of time."

She said that virtually all of her patients have received their medicines after she has gone through the new necessity of multiple phone calls to the District Medicaid office and pharmacies. "They authorize it almost immediately, which is really perplexing. What is the point?"

Doctors said that District Medicaid officials in explanatory teleconferences and webcasts told them that federal guidelines required the new policies.

A spokesman for the federal Centers for Medicare and Medicaid Services, known as CMS, said that is not the case. "These requirements were not mandated by CMS and are not a federal requirement," Jeff Nelligan said. "They are state options to manage their pharmacy benefit."

Maruca said that changes stem from the need to contain the rapidly growing cost of prescription drugs.

Last year, the District developed a list of preferred, less costly drugs for doctors to prescribe but gave them the option of substituting other medications. All prescriptions of some narcotic painkillers, such as Percocet, were supposed to require special preauthorization. But that was not enforced until about three weeks ago, when the new contractor took over administration of the District's Medicaid pharmacy plan, prompting the backlash from many doctors and pharmacists.

"It's just outrageous," said Michael Kim, who owns Grubbs Pharmacy on Capitol Hill, which serves many Medicaid patients and several members of Congress. "They don't have a good reason for what they're doing."

Kim said it is rare for an entire category of drugs to have such restrictions. "We think that's ridiculous," he said. "Patients have been suffering the consequences of this whole switch."

Doctors said that virtually all gastrointestinal medicines, including those to combat heartburn, require preauthorization. Maryland and Virginia allow generic versions of those drugs -- as well as other pain medications -- to be prescribed without preauthorization.

Maruca said that it is "medically sound" to require the authorizations for the pain medication and that the District does allow some gastrointestinal drugs without special authorization.

The doctor said they are concerned that Medicaid patients can be particularly vulnerable to problems with delays because they often have difficulty understanding medical instructions and frequently lack transportation that allows them to make multiple trips to pharmacies or doctor's offices.

Staff writers Chris L. Jenkins and Lisa Rein contributed to this report.