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‘Similarly effective’ could be new standard in Medicaid

Medicare & Reimbursement Advisor Weekly, June 17, 2009

State policy likely to affect treatment decisions

Medications that are similarly effective will be preferred for Connecticut Medicaid’s nearly 1 million residents in 2010, under a plan by the state to control spending. The move means patients and families will be given similarly effective drugs, not those deemed equally effective to treat a person’s condition. For example, a woman who’s been tolerating Lipitor or atorvastatin may have access only to simvastatin, the generic within the class, but one not therapeutically equivalent.

Other states are looking at various means to control Medicaid budgets.

In early June, we asked primary care physicians from 15 states, including Connecticut, if Medicaid policies for prescription medications affect their product decisions for treatment and by how much. We asked, “How likely is it for you to prescribe a drug based on what you write for your Medicaid patients?” On a scale of 1 to 10, with 1 equaling highly unlikely to affect product selection and 10 equaling highly likely, the average rating among 242 physicians was 7.84. Of the 242, 127 said Medicaid represented less than 25% of their practice, suggesting that the more restrictive the formulary, the more influence it has in therapeutic decisions since these practices are less able to challenge plan policies.

Of the 18 physicians from Connecticut, 14 provided a rating of 8 or higher.

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