GRAAHI Study Reveals Pharmaceutical Hurdles

May 23, 2008
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GRAND RAPIDS — Medicine for four common chronic illnesses can be tough to come by, especially for people who rely on Medicaid, a Grand Rapids African American Health Institute study shows.

Even though it’s cheaper to treat those health problems than waiting for a crisis that requires hospital care, GRAAHI Chairman Dr. Khan Nedd said, some coverage plans include barriers to getting medicines. That’s a problem for people with low-incomes and blacks, Nedd said, as many African-Americans are wary of a health care system that doesn’t always meet their needs.

“This is a population that’s already distrusting about health care. If any barriers are placed in front of them, we may lose them for good,” said Nedd, a Grand Rapids hospitalist. “These people get sicker, and it costs us more on the back side. Those are the folks who get heart attacks and strokes.”

The study, first released last fall and recently updated, scores 22 health coverage plans for access to the 100 most often prescribed drugs and sorts them into four categories: cardiovascular diseases, asthma, diabetes and mental health conditions. The report gives the plans an overall rating.

Blue Cross Blue Shield of Michigan is at the top for overall access to medicines, although the Blue Care Network and custom BCBSM products are ranked lower. Priority Health, the Spectrum Health-owned plan, ranked third. Health Plan of Michigan came in fourth, and was the top Medicaid HMO. Nonprofits BCBSM and Priority Health are the two biggest commercial plans in West Michigan.

A formulary is a list of medicines that an insurance company will cover, explained Larry Wagenknecht, CEO of the Michigan Pharmacists Association. Insurers consider such factors as groups of drugs for particular conditions and whether a generic version is available. “Each drug is a little bit different,” Wagenknecht said. “What does the drug do? And cost comes into play. Some are more generous formularies than others.”

At Priority Health, of Grand Rapids, a committee of pharmacists and physicians reviews formularies for the nonprofit insurer’s various products, said Associate Vice President for Pharmacy William Valler. The committee looks at whether a drug is safe and effective. He said there is little difference between formularies for commercial plans and the Medicaid HMO.

“Our Medicaid and commercial formularies do not differ greatly. Reimbursement is lower for our Medicaid product than our commercial product, which accounts for small differences in formulary coverage,” Valler said. “It is crucial to keep costs low, particularly in our Medicaid business, to assure we are able to provide coverage to a population who may otherwise not have medical or pharmacy coverage.”

Wagenknecht said the study points to the trend of value in health care, noting that while patients’ increased pharmaceutical use may push that line item higher, greater money is saved by avoiding emergency room visits and hospitalization.

“The concept of looking at rearranging or putting health plans together based on value issues is a direction that’s novel and actually is gaining a lot of attention in the country right now,” he said. “If you have a person that’s diabetic and you have a drug that has a co-pay pay higher than previously, it’s a greater barrier to the patient taking a drug that’s going to keep them out of the hospital.”

More research is being done that shows that even giving away chronic disease-management drugs saves money in the long run, he said. That might provide an impetus for changing Medicaid benefits, he added.

Nedd said generics are “just as good” as brand-name prescriptions in most cases and he’s not opposed to using them. “Far more, we believe the relationship between patients and doctors is a sacred and personal one. When the doctor makes a decision for a patient and the pharmacist says he can’t fill the brand name, that’s disturbing for a lot of patients,” Nedd said.

Different products with the same insurance company may have differing co-pays, require authorization or demand that a patient try other drugs prior to covering the one the doctor prefers. “We decided that anything that had a high co-pay or hassle factor that makes it tough for patients to get the drug is an impediment to good health care,” Nedd said.

In trying to prescribe the right drug with the least side effects, doctors need to find a delicate balance that can sometimes be disturbed by an insurance company’s formulary restrictions, he added.

For example, ACE inhibitors are a type of drug used to treat high blood pressure, the leading cause of kidney failure, both of which occur with greater-than-average frequency in the black population. Some 48 percent of people on kidney dialysis in the U.S. are black, while blacks make up 14 percent of the population.

But 21 percent of African-American patients may experience a cough or swelling as side effects of the drugs, which could reduce their willingness to take the medication, Nedd said. However, some health insurance plans — including BCBSM, with a high overall rank — won’t cover an alternative called “A2 receptor antagonists” unless the patient first fails on an ACE inhibitor.

“Once you get a side effect, these patients — the chances of getting them to take any other blood pressure medicine is very difficult,” Nedd said. “You can imagine the impact of that.”

Nedd said he hopes that consumers will use the report’s findings, posted on the organization’s Web site at, in choosing health insurance plans. The report details the ease of access by health plan for each drug studied.

“Most consumers may see the doctor one to three times a year,” Nedd added. “If you have a prescription medication, you have encounters with the pharmacy about 12 times a year. For most consumers, their interactions with health care are really spent at the pharmacy.”

Valler said Priority Health wants to keep drug costs down to dampen premium price creep.

“Drugs are a large component of rising health care cost,” Valler said. “Having a clinically sound, cost-effective formulary in place enables members to access the medications they need while also balancing rising costs.”

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