Pharmacy carve-out would harm Medicaid beneficiaries, put lives at risk
For years, Carol struggled to manage her multiple chronic conditions, including HIV and sickle cell disease. She was stuck in a cycle of emergency room visits, with seemingly no long-term solution on the horizon. But Carol’s situation changed when her Medicaid health plan’s pharmacy care management team stepped in to help.
They proactively reached out to Carol when they noticed she was making frequent emergency room visits for pain crises common for sickle cell patients. Pharmacy data revealed inconsistencies in filling prescriptions for both her HIV and a generic sickle cell treatment. Carol reported that she was only taking her medications intermittently because she was afraid of how the drugs might interact with one another.
The pharmacy team spoke with Carol, dispelling this misconception and assuring her that the medications were safe to take together. Without her pharmacy team’s intervention—and ongoing support—Carol would not have been able to manage her conditions.
Carol was able to get this help because New Yorkers with Medicaid have their pharmacy benefit integrated into all the other covered benefits patients receive from their health plan. But a policy set to take effect April 1, 2023 would dramatically change how Medicaid beneficiaries, including the most vulnerable New Yorkers living with chronic conditions, access the medications they need to live.
Under what is known as the pharmacy carve-out, Medicaid beneficiaries like Carol will lose access to a tailored formulary and specialized pharmacists with expertise in HIV, mental health and gender-affirming issues. These pharmacists utilize data in real time to resolve barriers to medication. The carve-out would lump all seven million Medicaid beneficiaries together under a single pharmacy benefit manager, leading to delays in accessing life-saving medication and disruptions in care.
“The pharmacy counter is where the rubber meets the road for many of the patients we see. This policy will lead to treatment delays that will needlessly put the lives of the most vulnerable New Yorkers at risk. If we want to tackle long-standing health disparities with an equitable, whole health approach, we cannot dis-integrate the pharmacy benefit from Medicaid managed care,” said Jacqui Kilmer, CEO of Harlem United, who is part of Save NY’s Safety Net, a coalition of healthcare providers and advocates.
California enacted the carve-out in their Medicaid program earlier this year, and the results have been disastrous. Thousands of people have gone weeks without their medications. Providers have faced authorization delays that make it harder to treat complex conditions. And the call centers set up to resolve problems have been overwhelmed, leading to long wait times. California has contracted with Magellan, the same pharmacy benefit manager New York has contracted with.
“Somebody is going to die if they haven’t already,” Dr. James Schultz, chief medical officer of Neighborhood Healthcare, which operates 17 clinics in Riverside and San Diego counties, told Kaiser Health News.
Had the carve-out been enacted when Carol needed help, things would have gone very differently. No one would have noticed that she wasn’t filling her prescriptions and proactively reached out to her to work through her concerns.
“The help I got from my health plan saved my life. Had my health plan not reached out to me when I wasn’t taking my medication, I would have continued to be in and out of the emergency room. I wouldn’t have gotten better,” Carol recalled. “Carving out the pharmacy benefit from Medicaid managed care will needlessly put the lives of millions of people like me at risk. The carve-out must be fully and permanently repealed. I ask those in power: how much is my life worth to you?”
Save New York’s Safety Net is a statewide coalition of community health clinics, community-based organizations and specialized HIV health plans committed to serving vulnerable New Yorkers across the state, ending the epidemic and saving the 340B drug discount program, which is in jeopardy. #CancelCuomoCarveOut
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