Wisconsin has moved about two-thirds of its Medicaid enrollees into privately administered managed care plans, known as BadgerCare. However, the state has been very slow to move Medicaid enrollees into managed drug plans. Virtually all state Medicaid programs distribute some drugs on a fee-for-service (FFS) basis separately from enrollees’ health plans.
A few states distribute almost all their Medicaid drugs this way; Wisconsin is one of them [see Figure I].2 This inefficient practice should change.
Reforming Medicaid Drug Programs. State Medicaid programs that carve out drug benefits often ignore drug therapy coordination and management. By contrast, integrating prescription drugs benefits with managed care health plans improves quality and increases efficiency. A Lewin Group analysis for Medicaid Health Plans of America, a trade association, found that integrating health and drug plans in 14 states that currently carve out drug benefits would collectively save nearly $12 billion over a decade.3
Private health plans that provide medical care to Medicaid enrollees are the logical entities to manage drug benefits. The health plans are paid a set fee per enrollee to provide care; thus, the plans are liable for the cost of nondrug therapies, whereas a drug regime is often a less costly substitute for surgery or other treatment.
Drug therapies often reduce the need for hospitalization, and avoid expensive emergency room visits and medical complications – especially for such chronic conditions as asthma, diabetes and schizophrenia. An IMS Health analysis of Medicaid managed pharmacy benefits in several states found utilization rates for many of these therapies is higher under managed care than fee for service.4
The Role of Medicaid Drug Plan Administrators. Private health plans use various techniques to control drug costs, including preferred-drug lists (PDL), formularies, required use of mail-order drug suppliers, negotiated prices with drug companies and drug distributors, and contracting with exclusive pharmacy network providers.5 Private Medicaid managed care plans frequently contract with pharmacy benefit managers (PBMs), private firms that act as third-party prescription drug plan administrators. PBMs process and reimburse claims, and negotiate drug prices and rebates with drug manufacturers. They also negotiate dispensing fees – the amount paid to pharmacies for the service of filling a prescription. Regardless of how a drug program operates, Medicaid enrollees generally obtain prescriptions at local pharmacies, which are reimbursed for each prescription filled.6
A recent analysis by the Menges Group identified ways in which privately managed Medicaid drug plans are more efficient than state-administered drug benefit programs.7 Rather than negotiating with pharmacy networks, state fee-for-service Medicaid programs often arbitrarily pay much higher dispensing fees than they would in a competitive market. These programs rarely utilize generic drugs. Moreover, FFS Medicaid faces political opposition to exclusive pharmacy network contracts.
For instance:
- Just over three-fourths (77 percent) of prescriptions in Wisconsin’s fee-for-service Medicaid plan are filled with generic drugs; the national average for managed Medicaid drug benefits is about 80 percent.
- Wisconsin Medicaid programs pays pharmacies $3.94 to dispense a prescription, whereas the average for private Medicare Part D plans is about one-half as much – about $2.00.
- The number of prescriptions per enrollee is generally higher among enrollees in Medicaid compared to managed care.
According to Menges, integrating drug and health benefits in a statewide managed care program over the next 10 years could save Wisconsin Medicaid over $2 billion in federal and state spending.8 Specifically [Figure II]:
- Nearly one-sixth (16 percent) of the savings would come from paying market-based, competitive dispensing fees.
- About half (49 percent) would come from use of generic drugs where appropriate.
- More than one-fourth (27 percent) would come from negotiating steep discounts with exclusive networks.
Despite the potential savings, pharmacy trade associations often oppose moving from FFS Medicaid drug programs to privately managed drug programs. They advocate laws to prohibit exclusive Medicaid pharmacy networks. They also lobby lawmakers to discourage cost-efficient, mail-order drug programs commonly found under managed care. The pharmacy industry has also launched another initiative in recent years to limit the ability of drug plans to audit pharmacies that bill for drug plan member prescriptions.9 If taxpayers are to be protected from fraudulent operators, drug plans must be allowed to audit for compliance.
A few of these barriers to efficient Medicaid drug plans are discussed in greater detail below.
Competitive Dispensing Fees. Many state fee-for-service Medicaid drug programs pay dispensing fees that are more than double the negotiated rates paid by private Medicare Part D drug plans. This is the case in Wisconsin. Community pharmacies often specialize in serving Medicaid beneficiaries and depend on dispensing fees to boost their revenue. Small pharmacists cannot compete with PBMs on price and efficiency without cutting profitability, so they fight to maintain the status quo and lobby to keep dispensing fees artificially high.
Barriers to Efficient Networks. Many pharmacists are small business owners, and state legislators often view them sympathetically when they lobby for protection from competition.
For instance, PBMs and health plans are increasingly experimenting with limited or “narrow” pharmacy networks in order to negotiate lower drug prices and dispensing fees. Pharmacies compete to become one of the exclusive network drug providers.10 Enrollees, insurers and employers share in the savings that result.11 However, many states allow any willing pharmacy to participate in Medicaid drug programs, preventing the development of exclusive networks.
Supporters argue that open pharmacy networks offer enrollees more choices and more convenience, and promote competition. But open networks aren’t competitive in the traditional sense. For instance, pharmacies are not offering lower prices to enrollees or state Medicaid programs in return for business. Pharmacies that compete with each other to be included in exclusive networks typically agree to deeper discounts that save taxpayers money.12
Any-willing-provider and freedom-of-choice laws reduce the drug plans’ power to negotiate steeper discounts from pharmacies.13 These regulations also prevent health plan sponsors from selectively negotiating and contracting with pharmacies.14 The Federal Trade Commission (FTC) notes that these laws lead to higher drug prices and higher premiums by protecting less efficient pharmacies from competition.15 Thus, they could be costly to taxpayers, employers and patients.16 The Lewin Group calculated that if government enacted a nationwide any-willing-provider mandate, prescription mail-order pharmacy costs would increase 3 percent.17 Thus, any-willing-provider and freedom-of-choice laws typically benefit local pharmacies rather than consumers.18
Barriers to Mail-Order Pharmacies. Drug plans offer incentives that encourage patients to use mail-order pharmacies for medications to treat chronic conditions, such as diabetes, hypertension and high cholesterol. Many plan sponsors charge higher deductibles for retail purchases, offer lower copayments for mail-order dispensing, or only reimburse patients for mail-order maintenance medications.19 Some plans limit the number of times a prescription may be refilled at a retail pharmacy before patients are required to use the mail.
Unfortunately, lawmakers sometimes pursue unwise policies designed to benefit local constituents. This is accomplished by enacting laws that limit drug plans’ ability to reward enrollees who use mail order. In 2011, New York State passed Assembly Bill 5502, which allows consumers to fill prescriptions at any pharmacy without incurring additional cost sharing or fees. The law benefits local community pharmacies – not consumers or taxpayers.
As one consultant described it: “Imagine that your local bookstore owner lobbied your state Senate to pass a law preventing you from buying a book less expensively via Amazon.com. You would immediately recognize that the bookstore was trying to protect its business at your expense. This is precisely what has happened for prescription drugs in New York.”20 The FTC agreed, stating, “By reducing competition between pharmacies, this legislation likely will raise prices for, and reduce access to, prescription drugs…”21
Retail-choice laws may increase convenience for some enrollees, but they drive up costs for all health plan members and plan sponsors. Maryland passed legislation similar to New York’s. If retail choice was required nationwide, mail-order prescription costs would rise more than 5 percent, according to the Lewin Group.22
Clearly, Wisconsin should avoid the mistake of allowing any willing pharmacy to participate in the Medicaid drug program rather than authorizing drug plan managers to negotiate lower prices with exclusive pharmacy networks. In addition, any-willing-pharmacy laws unnecessarily facilitate waste, fraud and abuse. For example, an unlimited supply of pharmacies allows unscrupulous patients to shop for multiple doctors willing to prescribe narcotics – avoiding detection by filling each prescription at a different pharmacy. Requiring Medicaid drug plans to reimburse large networks (with numerous small pharmacies) also makes it more difficult to detect billing fraud by pharmacy operators (or fake pharmacies). Wisconsin should also avoid calls by local pharmacies to interfere with mail-order programs.
Pharmacy Board Regulation. As in most states, the state insurance commissioner regulates insurance sold in Wisconsin, including health and drug plans. However, some states are transferring some regulatory authority over drug plans to their state board of pharmacy. This happened in Alabama, and a bill in Oklahoma would do likewise.23 In Arkansas, House Bill 2100, introduced in the first session of the 54th Legislature, would require PBMs to obtain a license from the pharmacy board. Pharmacists and their allies typically dominate the membership of such boards; thus, Arkansas passed a law in 2011 requiring the approval of the Arkansas Pharmacy Association for gubernatorial appointments to the State Board of Pharmacy.24The law also grants the Board of Pharmacy the power to demand sensitive information on business practices, which could be disclosed to pharmacy trade groups, eroding the bargaining power of the drug plans. Indeed, when the Mississippi House of Representatives debated this issue in 2013, the FTC argued that shifting drug plan regulation to state pharmacy boards would harm consumers – concluding that more restrictive controls would reduce competition and raise costs for consumers.25
Conclusion. Medicaid will best serve Wisconsin taxpayers by providing drugs to enrollees at the lowest possible cost. Wisconsin has moved many of its Medicaid enrollees into managed care plans. The state should also integrate drug benefits into enrollees’ health plans. In addition, legislators should avoid the temptation to enact protectionist regulations designed to limit competition among pharmacies participating in the Medicaid program. The state will likely find that drug plan managers will lower costs – if they allow drug plans to use the tools to do so. However, Wisconsin legislators will undoubtedly come under political pressure to protect local providers from the competition that could save taxpayers money.
Devon M. Herrick is a senior fellow with the National Center for Policy Analysis.
1. “Medicaid Managed Care Enrollment Report,” Summary Statistics, Centers for Medicare and Medicaid Services, July 1, 2011. Available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Downloads/2011-Medicaid-MC-Enrollment-Report.pdf.
2. Joel Menges, “Medicaid Pharmacy Savings Opportunities: National and State-Specific Estimates,” Menges Group, May 2013. Available at http://www.pcmanet.org/images/stories/uploads/2013/final percent20medicaid percent20savings percent20report percent20menges percent20group percent20may percent202013.pdf.
3. Joel Menges et al., “Projected Impacts of Adopting a Pharmacy Carve-In Approach Within Medicaid Capitation Programs,” Lewin Group, February 2011. Available at http://www.lewin.com/content/publications/MHPAPaperPharmacyCarve-In.pdf.
4. Murray Aitken et al., “Shift from Fee-for-Service to Managed Medicaid: What is the Impact on Patient Care?” Institute for Healthcare Informatics, April 2013.
5. Joel Menges, “Medicaid Pharmacy Savings Opportunities: National and State-Specific Estimates.”
6. Devon M. Herrick, “Increasing the Cost-Effectiveness of Medicaid Drug Programs,” National Center for Policy Analysis, Policy Backgrounder No. 164, April 29, 2011. Available at http://www.ncpathinktank.org/pdfs/bg164.pdf.
7. Joel Menges, “Medicaid Pharmacy Savings Opportunities: National and State-Specific Estimates.”
8. Ibid.
9. For example, see “Survey of Community Pharmacies Impact of Pharmacy Benefit Manager (PBM) Contracting and Auditing Practices on Patient Care Wisconsin,” National Community Pharmacists Association, 2011. Available at https://www.ncpanet.org/pdf/pbm_survey/Wisconsin.pdf. H.R. 1971 had 34 cosponsors but did not pass out of committee.
10. “As Pharmacy Networks Slim Down, Payers Have a Lot to Chew On, Suggests Experts,” Drug Benefit News, Vol. 13, No. 12, June 22, 2012.
11. Thomas Gryta, “What Is a ‘Pharmacy Benefit Manager’?” Wall Street Journal, July 21, 2011. Available at http://online.wsj.com/article/SB100014 24053111903554904576460322664055328.html.
12. Ibid.
13. Alain Enthoven and Kyna Fong, “Medicare: Negotiated Drug Prices May Not Lower Costs,” National Center for Policy Analysis, Brief Analysis No. 575, December 18, 2006. Available at http://www.ncpathinktank.org/pub/ba575.
14. Christine Piette Durrance, “The Impact of Pharmacy-Specific Any-Willing-Provider Legislation on Prescription Drug Expenditures,” Atlantic Economic Journal, Vol. 37, No. 4, August 2009, pages 409-423.
15. “Improving Health Care: A Dose of Competition,” Federal Trade Commission and the U.S. Department of Justice, July 2004. Available at http:// www.ftc.gov/reports/healthcare/040723healthcarerpt.pdf.
16. Susan S. DeSanti, Joseph Farrell and Richard A. Feinstein, Letter to New York State Senator James L. Seward, U.S. Federal Trade Commission, August 8, 201. Available at http://www.ftc.gov/os/2011/08/110808healthcarecomment.pdf.
17. Lewin Group, “Mail-Service Pharmacy Savings and the Cost of Proposed Limitations in Medicare and the Commercial Sector,” Pharmaceutical Care Management Association, September 2006. Available at http://www.lewin.com/~/media/Lewin/Site_Sections/Publications/3480.pdf.
18. Robert L. Ohsfeldt et al., “The Spread of State Any-willing-provider Laws,” HSR: Health Service Research, Vol. 35, No. 5, December 1998.
19. “Pharmacy Benefit Managers: Ownership of Mail-Order Pharmacies,” Federal Trade Commission, August 2005.
20. Adam J. Fein, “The Unexpected Losers from New York’s Anti-Mail Bill,” Drug Channels, June 28, 2011. Available at http://www.drugchannels. net/2011/06/unexpected-losers-from-new-yorks-anti.html.
21. Susan S. DeSanti, Joseph Farrell and Richard A. Feinstein, “letter in response to a request for comments on the likely competitive effects of New York Assembly Bill 5502-B,” Office of Policy Planning, U.S. Federal Trade Commission, August 8, 2011. Available at http://www.ftc.gov/os/2011/0 8/110808healthcarecomment.pdf.
22.This provision also requires PBMs to reimburse for 90-day prescriptions through local pharmacies. See Lewin Group, “Mail-Service Pharmacy Savings and the Cost of Proposed Limitations in Medicare and the Commercial Sector,” Pharmaceutical Care Management Association, September 2006. Available at http://www.lewin.com/~/media/Lewin/Site_Sections/Publications/3480.pdf.
23.For example, see Staff, “Oklahoma bill would give Board of Pharmacy oversight of PBMs,” February 13, 2013. http://drugtopics.modernmedicine.com/drug-topics/news/drug-topics/associations/oklahoma-bill-would-give-board-pharmacy-oversight-pbms.
24. “Arkansas State Board of Pharmacy Law Book, Pharmacy Practice Act, July 2011,” 17-92-201, Members-Qualifications, Arkansas State Board of Pharmacy, page 47. http://pharmacyboard.arkansas.gov/licenseeInfo/Documents/lawBook/pharmacyPracticeAct.pdf.
25. See Susan S. DeSanti, Joseph Farrell and Richard A. Feinstein, letter in response to a request for comments on the likely competitive effects of Mississippi Senate Bill 2445, Office of Policy Planning, U.S. Federal Trade Commission, March 22, 2011. Available at http://www.ftc.gov/os/2011/03/110322mississippipbm.pdf.