Costly Prescriptions Go Unfilled, Medicaid Study Says

WASHINGTON —  Adding to the perception that prescription drug costs are burdensome for a growing number of Americans, a new national study shows that more than one in four Medicaid recipients could not afford at least one prescription medication in the previous 12 months.

And the proportion of Medicaid patients who had to leave at least one prescription unfilled was highest--one in three--in states that have done the most to control their Medicaid drug costs, according to the survey of 33,000 families.

The study, to be released today by the nonprofit, nonpartisan Center for Studying Health System Change, is the latest to indicate that even as prescription drugs become more effective in the treatment of disease and chronic medical conditions, more Americans are having trouble paying for them.

While Congress and the Bush administration are under increasing political pressure to make prescription drugs more affordable for seniors, the new study indicates that all segments of the population are having a hard time covering their cost. It found that 23 million American adults, or 12% of the nation’s adult population, could not afford to have at least one prescription filled in the previous year.

But the study’s authors were most troubled by the finding that 26% of the 39 million Americans enrolled in Medicaid--the federal-state health care program for the poor--had to forgo getting a prescription filled because of cost. The proportion of adults with no health coverage at all who could not afford at least one prescription--29%--was only slightly higher.

“Medicaid is expected to ensure access to affordable care for the poorest and sickest Americans,” Len Nichols, the center’s vice president, said Monday. “The study raises serious questions about the impact of state efforts to control Medicaid drug spending.”

More than half of Medicaid recipients ages 18 to 64 have a chronic condition such as diabetes, arthritis, heart disease or cancer, and more than a quarter suffer from at least two such conditions. In addition, more than half of all nonelderly adult Medicaid beneficiaries have incomes below the federal poverty level of $8,590 for a single person.

As a result, Nichols said, private sector cost-control methods such as requiring the use of generic drugs and imposing co-payments do not translate well to the Medicaid program, whose beneficiaries need more prescription drugs and have less money to pay for them.

Yet Nichols was quick to acknowledge that prescription drugs--the nation’s fastest-growing health-care cost--are straining state, as well as personal, budgets.

From 1997 to 2000, Medicaid expenditures for drugs grew at least 50% in all but two or three states, and by 90% or more in seven states, according to earlier studies by the federal government and the Kaiser Family Foundation.

Given that rate of increase, state governments are “very justified” in restricting the drugs Medicaid patients can get without special approval, limiting the number of prescriptions Medicaid will cover each month, increasing prescription co-payments or imposing other cost-control measures, said Joan Henneberry, director of health policy for the National Governors Assn.

The study found that adult Medicaid patients who lived in states that have instituted four or five cost-control measures--including West Virginia, Arkansas, North Carolina and South Carolina--were twice as likely to have trouble affording prescription drugs as those who lived in states with only one or two such restrictions. But with the economic downturn and spending increases causing budget crunches in almost every state, many Medicaid programs are imposing or considering new limits on prescription drug coverage.

“Nobody wants to keep necessary medications out of the hands of Medicaid enrollees” but states “have to do something,” Henneberry said. “They’re trying to manage this benefit in a fiscally responsible way.”

Gail Margolis, director of Medi-Cal, said that with careful management, California’s Medicaid program has prevented prescription drug costs from spiraling out of control.

Medi-Cal limits the drugs it covers with “a very sophisticated and expansive [drug] formulary,” she said, and Medi-Cal beneficiaries pay a $1 co-pay per prescription. Beneficiaries also are limited to six prescriptions per month; for additional prescriptions, the patient’s doctor must file an authorization request.

Perhaps most important, Margolis said, are the large discounts the state has negotiated with drug manufacturers.

Indeed, some consumer advocates said the new study shows that states wanting to control prescription drug costs should target the pricing policies of the industry, rather than the consumer.

But the pharmaceutical industry, contending that its products are often the most cost-effective form of health care treatment, simply pointed the finger at state governments.

“Medicaid program directors who face tight budgets should thoroughly study their entire system rather than automatically cutting the pharmaceutical benefit,” Alan F. Holmer, president of the trade group Pharmaceutical Research and Manufacturers of America, said in a statement.