Medicaid Pharmacy Rebate Program and Medicaid MCOs: Policy Recommendations for an Enhanced Public/Private Partnership

摘要

The National Association of Urban-Based HMOs, Inc. (NAUHMO) is a non-profit 501(c)(3) organization, established in 1993, comprised of health plans with a mission of service to vulnerable populations. NAUHMO is committed to ensuring the highest level of care and service to these populations. NAUHMO is further committed to the premise that the success of Medicaid managed care ultimately rests upon a true public-private partnership wherein resources of all partners are maximized and all partners are committed to the investment in the unique healthcare needs of some of our societys most vulnerable citizens, Medicaid recipients. Currently access to funds, specifically through the Medicaid Drug Rebate Program established by the OBRA 90 legislation, is denied to those Medicaid plans that the states have entrusted to manage the health care of their most vulnerable constituents, Medicaid recipients. It is NAUHMOs contention that the original intent of the OBRA 90 legislation was not, in fact, to deny Medicaid MCOs access to funds generated through the Medicaid Drug Rebate Program and that the intent was not to grant states sole access to these funds. This paper presents an overview of issues and recommendations relative to the participation of Medicaid MCOs in the Medicaid Drug Rebate Program. The member plans of NAUHMO have observed that a critical variable in coordinating the healthcare of our managed care enrollees while managing the costs for coordinating the healthcare is the pharmacy benefit. Medicaid MCOs have experienced first hand the deleterious impact that pharmacy exacts upon their operational budgets and in managing the premium dollars they receive from the state-federal funded program. While Medicaid MCOs, such as NAUHMO members, currently employ aggressive tactics in managing the pharmacy component of their managed care plans, such as formulary management, utilization management, generic substitution, and others, one critical cost-savings tool, the Medicaid Drug Rebate Program, is currently inaccessible.