Appeal on Behalf of the Poor
To: Governors, State Senators, State Attorney Generals, HHS Secretary, Medical Directors, State Medicaid Director, State District Justices, the people
A Special Request on behalf of Medicaid patients, poor people in the state, and those who care for them
From those who provide care for them:
Please stop policies that disrupt health care and injure poor people that are under your care.
What has happened?
In desperate financial times, the state has attempted to make cuts in health costs. The most rapidly expanding area in state budgets is health care. The greatest increases in health costs have been prescription costs. Nearly every state has enacted co-pays and required approvals of the most expensive medications for Medicaid patients. Studies predict savings, but few studies include the actual costs of such policies. In Nebraska this policy is only a few months old, but already patients have been injured. Patients are not getting prescriptions filled. Of great concern is medications for children, pregnant women, those mentally ill, elderly patients on fixed incomes, and those with serious and chronic illnesses.
What is the current impact of these policies?
Patients are frustrated and confused. Pharmacists know that patients are not filling their prescriptions. They are concerned because they know that certain patients really need their medicines badly. Pharmacists in Texas obtained a court injunction stopping such policies. Some patients have been unable to get needed medications and have gotten ill and had to go into the hospital, some in serious condition. Patients are not telling their doctors that they are not getting their prescriptions filled.
Doctor’s offices are in turmoil trying to get patients the medications that they need and have had for years. Nurses and others in doctor’s offices have less time to care for patients. Those taking care of many poor people already suffer from lower reimbursements. In eastern Omaha some 12 – 15% of the people lost all forms of health insurance with recent state cuts in Medicaid, yet these providers continue to care for patients. Medicare has cut reimbursements also.
Distortions in Health Care
The current situation is a partnership between patients and physicians and pharmacists. Patients and physicians decide together what medicines are needed. Patients go to pharmacists for the medications. Pharmacists give information to patients and physicians. Medications act to help reduce the need for doctor visits and hospitalizations. There is currently an equilibrium that has been worked out over decades. There are checks and balances to provide good quality.
Now the situation is different. Patients and physicians still decide about medications, but sometimes patients elect not to go to the pharmacist at all. They have other needs that are more important to them than getting their medications. They do not know how to change such policies and often feel that any efforts they might make are useless. They are easily ignored. Pharmacists know that Medicaid patients are not filling prescriptions, but they do not see the effects on the health of poor people. Doctors see the health problems in the poor people, but often do not know that these are because patients are not taking the medications that they have prescribed.
What is the likely effect of these policies?
Some medications have little impact on health. Others have not been studied thoroughly. The following medications do have great impact on health. Here are a few of the types of patients and the likely result of current policies:
|
Type of Disease |
Medication |
Result |
Time frame |
|
Peptic Ulcers, duodenal ulcers, |
Proton Pump Inhibitor (purple pill) |
Hospitalization or death from ulcer |
Weeks to months |
|
Diabetes |
Insulin, anti-hypertensives |
More doctor visits, specialist care, and hospitalizations for infections, diabetic ketosis, and eye and kidney problems |
Months to years |
|
Depression |
Antidepressants |
Suicides, disability, lost jobs, injury to children of depressed patients |
Weeks to months. Likelihood that other citizens will likely be injured or adversely impacted is high |
|
Asthma, allergies |
Inhalers Antihistamines, non-sedating type are restricted |
More hospitalizations, doctor visits Poor children with allergies forced to take sedating antihistamines or no medication at all, resulting in more challenges for an education already more difficult due to maldistribution of educational resources and low education expenditures in state |
Weeks to months |
|
Schizophrenic or mentally unstable patients |
Anti-psychotic medications |
Studies in New Hampshire during one year’s time documented 17 times increased costs compared to the predicted savings – hospital, institutional, ER, doctor visits, not counting legal, jail, social service, and other costs |
Weeks to Months Likelihood that other citizens will likely be injured or adversely impacted is high |
|
High Blood Pressure |
Anti-hypertensives |
Steady increase in number of stroke patients, dialysis patients, heart victims |
Years |
|
Chronic Pain |
Pain medications, non-steroidal medications, antidepressants, muscle relaxers |
More narcotic use and abuse, more disability, more and earlier surgery for joint replacement, more doctor visits |
Months to years |
|
Multiple Medications |
Many patients have several of the above diagnoses |
More visits to doctor and emergency room and other care |
Months to years |
|
|
|
|
|
The real purpose of a co-pay is to keep patients from filling the medications that they and their doctor decided would be best for their health. In effect the state has stepped into an area formerly reserved for doctor and patient and pharmacist. The co-pay is not a good source of revenue, even a $2 co-pay is enough to keep patients from filling any prescriptions. For people that are not poor, a co-pay is not an impediment. They also tend to have more education and understand the need for taking their medication. Poor people on fixed incomes do not have the same ability to take funds from other sources to pay for medications.
Those with several medications will be forced to chose which to take. A few patients will die, even more will be disabled temporarily or permanently, some will require institutionalization and expensive long term care, others will visit emergency rooms and doctors offices more frequently, thus negating any savings in costs.
When patients do not take medications, doctors ask them to come back more frequently to the office and do expensive tests to find out why, increasing the cost of care.
Patients will have to bring lawsuits against the state because of injuries to them, since the state has now begun to make medical decisions and will be responsible for these decisions. These court battles will be bitter and long-lasting and expensive for the state and for patients.
What if we do nothing:
We will continue to hear how much money we are saving but we will watch health care costs go up at a higher and higher rate. can continue to expect These policies will expand to other medications and likely will begin to include medical tests and procedures.
What should we do?
First of all, we should stop restricting medications for patients where there is a potential for injury or increased cost of health care. Some states such as Utah have excluded certain groups of patients for fear of injury.
Second, we should require that states or insurance companies prove with actual studies (not just calculations) that policies will not harm patients by studying the impact on the patient now, on patients in the next months or years, and on other people. Proper studies are not just estimates of savings, they should include the costs of implementing the policy to patients, health providers, and those outside of the health care segment, including such areas related to health care such as education and the justice system.
Third, we should be ashamed that we fail in mental health, drug and alcohol, and public health spending.
Finally we should examine the particular factors that lead to poverty and hold people in it’s bondage. It is no surprise that we have increased Medicaid costs and increasing numbers in poverty since we do so poorly in health care and education, the main ways that families escape poverty.
Do not buy the myths being marketed to the public that poor people on programs are lazy. They are not driving expensive cars and living in luxury. Many have been damaged by our own neglect. Patients who deserved justice because of accidents, workers’ compensation injuries, and in service to our country have joined the ranks of the poor. Others could have made it out of poverty with better education or better legal help. Day care and transportation, other recent victims of budget cuts, are also important to those hoping to escape poverty.
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