The Solution

Healthcare professionals have the expertise to know what is best for patients and must have access to a full range of therapeutic options to use as they see fit for their patients. They should not have to jump through burdensome administrative hoops to secure the most appropriate therapy. Ultimately, healthcare professionals, not insurance companies, should make the determination of the best course of treatment and medications for a patient.

If we change the current program, Texas runs the risk of losing hundreds of millions of dollars in rebates – which is a method of finance in the budget. The current program balances both costs and patient safety– The insurance company carve-in scheme relies on reductions in access for Texas patients. In addition, the open public process for stakeholder input, including that of medical professionals, is eliminated. Only the insurance companies— not patients, not doctors, and not the State—stand to benefit.

The current program works for patients and for Texas

  • Texas spends the lowest per-enrollee on prescription drugs.
  • Texas average net cost per prescription is lower than the national average.
  • Texas spends less than 47 other states on Medicaid.

  • Texas leads the nation in percentage of rebates negotiated with manufacturers, ranked 3rd nationally.

The current program treats all patients equally, regardless of what part of the state they call home.

The Situation

Insurance companies are once again actively selling a plan to adopt a total “carve-in” of the state’s Medicaid Vendor Drug Program, claiming that Texas is potentially losing out on savings. Based largely on giving health plans more power to create restrictions on access to medicines, the “carve-in” scheme has been rejected by the Texas Legislature over and over again.

The current program works

The current program treats all patients equally, regardless of what part of the state they call home.

  • Texas leads the nation in percentage of rebates negotiated with drug manufacturers.
  • Texas average net cost per prescription is lower than the national average.

Texas costs for prescriptions per Medicaid enrollee is less than costs in 45 other states.

The current system works— balancing cost and patient safety

There are important patient protections in place:

  • Requiring a quick response to all prior authorization requests
  • Permitting emergency prescription fills while prior authorization requests are pending
  • Doctors are involved in the development of the preferred drug list, utilizing medical knowledge and expertise
  • Cost is factored into development, but safety and efficacy are factored in as well
  • Patients have an avenue for participation and public comment
  • Patients who are particularly sensitive to formulation changes have a wide range of medications available to treat their condition, preventing costly hospitalizations

Overly aggressive fail first protocols can prevent a patient from getting the right medicine in a timely manner. Fail first requirements that disrupt continuity of care are not good medicine. Fail first may prove to be more costly in both dollars and treatment effectiveness. Doing away with the current system could create arbitrary and unnecessary barriers to access medically necessary drug therapies for patients and ultimately lead to increased cost to the State. Investing in medicines on the front end lowers overall healthcare costs in the long-term.

The current program recognizes the importance of life-improving and life-saving innovator drugs and their role in controlling disease and related costs.

Texas could lose hundreds of millions of dollars

  • Texas operates the nation’s third largest Medicaid program, in terms of spending. Yet, its per enrollee retail pharmacy costs rank 43rd of the 50 states and ninth out of the ten largest states.
  • Manufacturers pay $1.5 billion annually in prescription drug rebates.
  • Texas receives additional or “supplemental” rebates on top of the statutorily-required Medicaid drug rebates.
  • Supplemental rebates amount to nearly $138 million annually.
  • Texas has been very successful in leveraging its significant negotiating power to secure significant rebates on innovative medicines.
  • Texas has one of the lowest Medicaid retail drug spends in the nation at 3.5%. Clearly, the state has been extremely successful in managing pharmacy costs under the current system.
  • Patient Access Texas is a coalition of patient, healthcare professional, and business organizations committed to public policy to ensure access to health care and treatment for Texans.