Medicaid patients dread new program

Associated Press

It took years for Tom Gadowski to develop a drug regimen that controls his manic depression. Some drugs gave him migraines, others made him severely ill.

Gadowski now takes seven medications that cost $1,100 a month.

Without the pills, he says, he has severe panic attacks, violent outbursts, rapid mood swings and thoughts of suicide.

``I've been on everything, and what I'm on right now seems to have me most stable,'' said Gadowski, 46, of Warren, who is unemployed and classified as permanently disabled.

Medicaid pays about half his drug costs each month; he pays the rest from his Social Security check.

Gadowski's medical regimen could be at risk under a new state plan to reduce rising drug costs.

The plan would allow doctors to prescribe only certain discounted medications to the 1.6 million low-income patients who rely on state aid, including Medicaid and programs for infants and the elderly. Doctors would have to get authorization for medications not on the list.

Drug companies that refused to provide discounts risked removal of their drugs from the list. As a result, such well-known drugs as Prozac, Ritalin, the arthritis drug Celebrex and the antibiotic Cipro didn't make the list.

If the plan goes into effect, it would be the most sweeping attempt to cut state drug costs in the nation.

In Florida, a similar program limited to Medicaid patients was upheld by a federal court judge earlier this month. Maine prohibits doctors from prescribing expensive drugs to low-income patients without permission, while Indiana limits low-income patients to four brand-name drugs per month.

The Michigan Department of Community Health says the state's Medicaid prescription costs have reached $1 billion a year and the new program could save at least $42 million this year.

The program was scheduled to begin Jan. 14, but has been temporarily blocked by Ingham County Circuit Court Judge Lawrence Glazer. On Jan. 7, Glazer said the state overstepped its authority because it didn't get approval for the plan from the full Legislature. The state has filed an emergency appeal.

The Department of Community Health says the plan won't compromise care.

The list of preferred drugs was developed by a team of 11 physicians and pharmacists recommended by the department and selected by GOP Gov. John Engler.

The department also points out that health maintenance organizations issue similar preferred lists to their physicians.

``We are not trying to incorporate something that is completely unheard of in the market,'' said Department of Community Health spokeswoman Geralyn Lasher.

But Gadowski says the program could unravel years of treatment. The drugs he takes that didn't make the list include the anti-depressant Wellbutrin, which he says costs about $125 a month, and the anti-inflammatory drug Vioxx, which costs about $115 a month.

Drug companies are infuriated because Michigan developed the list without their input, then told companies they would have to offer discounts beyond those the federal government already requires. The state defends its decision.

``It was done quietly because we wanted to be able to put forward a sound plan without that line of lobbyists trying to shape the plan in their best interests,'' Lasher said.

The Pharmaceutical Research and Manufacturers of America, or PhRMA, sued the state Nov. 30. The Washington trade group, which represents more than 40 companies, says Michigan overstepped its authority.

PhRMA represents those who refused to cooperate with Michigan's plan, including Pfizer Inc., Merck & Co., Eli Lilly and Co., Pharmacia Corp., Johnson & Johnson and Wyeth-Ayerst Pharmaceuticals.

Companies with a number of drugs on the preferred list include Schering-Plough Corp., the maker of the allergy drug Claritin, and Bristol-Myers Squibb Co., the maker of the anti-depressant Paxil.

A spokesman for Schering-Plough said the company wouldn't comment. A spokeswoman for Bristol-Myers hung up on a reporter seeking comment, then didn't return a telephone message.

Dr. David Johnson, the state's chief medical executive and head of the 11-member committee, said the list was written in several phases.

First, the committee listed what it considered the best drugs in 40 categories, substituting generics whenever possible. If manufacturers refused to discount the drugs on that list, committee members could make a case for the drugs to stay. In many cases, Johnson said, those drugs remained.

Doctors who want to prescribe drugs not on the list will have to call a technician trained to ask a series of questions.

For example, technicians would ask the doctor if the patient is allergic to the preferred drug.

If the technician denies approval, the doctor can appeal to a pharmacist, then to a state physician.

Johnson said that process will not be as time-consuming as opponents make it out to be. He also said exceptions may be made for patients like Gadowski.

``We're not going to make this an onerous process,'' he said.

But some patients find it hard to trust the state. Medicaid recipient David Halboth, who suffers from severe depression, says it took him a decade of trial and error before he went on the anti-depressant Zoloft.

The drug is not on the state's preferred list.

``You've got a group of people who struggle on a daily basis to maintain a decent quality of life, and the state is making it much, much harder,'' said Halboth, 41, of Holly.

``It will, in the long run, cost more to not properly care for people with mental illnesses,'' he added.