Would a Medicare Drug Plan Follow Oregon's New Drug Rationing Process?

Oregon Health Plan demonstrates government process that could be used to limit medication access in a Medicare Drug Benefit plan

St. Paul, Minnesota - If Congress passes a Medicare drug benefit next year, the Oregon Health Plan has provided federal officials with a process to limit medication choices. This should worry current and future Medicare recipients, says Citizens' Council on Health Care (CCHC), a Minnesota-based health care policy organization.

"If a Medicare drug plan ever becomes law, we have no doubt that a federal task force will be set up to tell seniors what pills they can have, what pills they can't have, how many and for how long," says Twila Brase, president of CCHC.

To cut the cost of medication for its Medicaid population, Oregon's 11-member Health Resources Commission has begun to evaluate the effectiveness of drugs in various classes. Decisions to include or exclude drugs from the state's drug formulary - a list of approved drugs - began with effectiveness and ended with price. Although some medications showed no difference in effectiveness, the drug with the lowest price was approved for the formulary, according to The Oregonian. After August 1, 2002, claims for medications that are not on the list will not be paid, unless the doctor asks for an exception. Such a request can be made on the prescription.

"Rationing is often an incremental process," cautions Brase. "The exception process should not be viewed as a permanent fixture. As costs increase, exceptions can be eliminated. Furthermore, no doctor wants to have to explain to a government official why they repeatedly request exceptions. The pressure to conform will be enormous."

The evaluation process was an outgrowth of a 2001 Oregon state law, which requires recipients to "receive the most effective prescription drug available at the best possible price." Only drugs for cancer, mental illness and AIDS are exempt from the evaluation process.

As evidence of CCHC's concerns, The Oregonian quoted Tricia Neuman, vice president of the Kaiser Family Foundation and director of its Medicare Policy Project, as saying, "Nationally, there is a lot to learn from what Oregon is pursuing."

"Medicare is not be exempt from the rationing of health care services, and will be less so as babyboomers reach Medicare age. But what makes this more worrisome is that Medicare recipients may not be allowed to receive medications that are not on the government list of drugs," warns Brase.

In 1997, as part of the Balanced Budget Act, Congress enacted a prohibition on private payment by Medicare recipients for health care services. If the services are covered by Medicare, but not approved for the patient, physicians are not allowed to accept private payment from the patient, even if the patient is willing to pay. The only doctors who can accept private payment are those who have dropped out of Medicare participation for at least 2 years.

"Specific medications can be critical to the length and quality of life of an individual. Senior citizens should not be so quick to rally around a government-sponsored drug benefit. Determining medication access by committee consensus does not paint a rosy picture for the future of Medicare recipients." says Brase.

Media Contact:

Twila Brase, President and Co-founder
Office: 651-646-8935