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NY must keep Medicaid pharmacy benefit: Albany ‘exclusion’ puts too many at risk


On April 1, the New York State Department of Health must “dissolve” the Medicaid managed care pharmacy benefit, switching to a fee-for-service model that is intended to increase savings through lower pharmacy costs . However, the proposed change will cause unnecessary harm to New York’s most vulnerable populations, including those diagnosed with HIV, and will not achieve the expected savings.

Medicaid managed care plans, including HIV Special Needs Plans (HIV SNPs), aim to manage cost, utilization, and quality. Collectively, as MetroPlusHealth, VNS Health SelectHealth and Amida Care, we serve more than 16,000 Medicaid members who are living with HIV or at elevated risk of HIV because they are homeless, transgender or gender non-conforming.

These members rely on coordinated care and effective pharmaceutical benefits to suppress HIV or remain HIV negative, which are monitored by care managers to ensure medication adherence. This leads to improved individual health outcomes and the state’s goal of “Ending the Epidemic” while improving health equity and protecting vulnerable New Yorkers.

The pharmaceutical exclusion proposal will have considerable impacts. Currently, through coordinated care management, plan members receive timely internal resolution of issues related to their pharmacy benefits. When providers change failing therapies, our care teams work collaboratively to ensure a smooth transition to a new one.

Addressing members’ complex medication adherence needs requires careful care management and real-time integration of medical and pharmaceutical information. Our plans use pharmacy data to facilitate medication reconciliation and support treatment adherence and care transitions. It is critical in the development of clinical programs where medication treatment is a factor, such as chronic disease management, opioid substance use disorder, and serious mental illness.

We recognize that such transitions are critical for members with HIV, so we work to avoid discontinuation of the member’s pharmacy benefit. This not only directly benefits members, but also supports public health goals such as preventing virus replication and mutation, achieving viral suppression, and ultimately eradicating HIV through reduced transmission rates.

In lieu of the proven value of our customer care and relationship management, the proposed opt-out promises red tape and bottlenecks. If the proposal stands, members will have to use a single state call center instead of being assisted by their family care managers. This simplification of case resolution will result in a loss of trust and expectations of efficient care that members have come to trust.

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Designated AIDS Centers, FQHCs, and NYC Health+Hospitals rely on funds from the 340B Drug Pricing Program. This law requires drug manufacturers to sell outpatient drugs at reduced prices to safety net providers who serve low-income and vulnerable New Yorkers. The proposed exclusion will result in a loss of more than $300 million in annual funding and will force many places to close, resulting in the loss of necessary care and services for members, such as housing, nutrition and transportation.

Our organizations function like the three HIV SNPs in New York City. Together, we recognize the likely harms of pharmaceutical exclusion, both to our members and to the safety net health care system. Therefore, we have come together to ask Governor Hochul to repeal this decision.

The pharmacy exclusion will negatively affect HIV SNP members and plans, disproportionately affecting people of color and the LGBTQ+ community. If implemented, exclusion will markedly reverse ongoing gains in prevalence decline and contribute to harm to individual members.

New York can learn from the mistakes of California, Ohio and Michigan, which switched to fee-for-service pharmacy benefits. These states suffered negative consequences, with residents not having access to critical medicines for weeks. Without clear guidance on how Albany intends to prevent such problems, we cannot support a proposal that we know will put members at risk.

The current three-point plan, aimed at diagnosing and linking undiagnosed people with HIV to care, keeping people with HIV in care for virus suppression and preventing transmission, and facilitating access to PrEP for people high-risk, is making progress in reducing HIV prevalence. In New York. The proposed exclusion will cause confusion among vulnerable groups, including those in HIV SNPs.

Fortunately, there is a sensible alternative. This approach achieves the state’s policy goals, prevents patient disruption, preserves the safety net, supports community pharmacies, maintains benefit in managed care, and saves money. If the Governor and the Legislature cannot reach an agreement to repeal the exception, we urge that this solution be adopted in this year’s budget.

Schwartz is president and CEO of MetroPlusHealth, Abdelaal is president of VNS Health plans, Wirth is president and CEO of Amida Care.

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