On
behalf of more than 25,000 physicians and medical students across the
Commonwealth, the Massachusetts Medical Society appreciates the opportunity to
provide comment regarding the amendments proposed to the MassHealth 1115
Demonstration Waiver, as released on July 10, 2017. The Medical Society is
pleased to reiterate its support of the intent of the waiver to promote health
care delivery reforms that will help ensure the sustainability of the
MassHealth program which provides vital coverage to so many patients in
Massachusetts.
The
Medical Society writes to express significant concern regarding several of the
proposed amendments which we believe on balance will have detrimental effects
on the care provided to MassHealth beneficiaries. The Medical Society endorses the comments provided by Health Care for
All and other co-signatories in its August 18th letter to you
regarding these waiver amendments. We believe that shifts of large patient
populations from MassHealth to ConnectorCare will ultimately burden patients
with reduced benefits and increased cost-sharing for these patients. Not only
could this lead to poorer health outcomes, but exacerbated oral health, mental
health and behavioral health issues could also lead to increases in overall
health care expenditures over time.
In
addition to the comments raised in the aforementioned letter, the Medical
Society wishes to provide further comment regarding two provisions: proposed
changes to the prescription drug formulary and the proposed further narrowing of
networks in the PCC plan.
Drug Formulary
The
Medical Society urges caution in moving from the current pharmacy benefit to a
closed drug formulary. While the Medical Society acknowledges the unsustainable
escalation of health care costs, with strong evidence of the role of
pharmaceutical drugs costs in driving these cost increases, a balance must be
sought in cost-saving policy proposals to ensure access of all patients to
medically necessary and appropriate prescription medications.
The
Medical Society therefore offers the following considerations for the
MassHealth drug formulary moving forward:
- A drug formulary should have clear,
consistent policies that outline inclusion criteria with opportunities for
expert and public comment
- Formulary development should be
continuous and transparent, with significant input by physicians into all
formulary development.
- Formularies
should be readily available in print and through electronic media to patients
and prescribers
- Formularies
should be continuously updated to respond to newly approved drugs, and to
ongoing feedback from patients and physicians
- Drug
formularies must be flexible to acknowledge the value of multiple drugs across
a drug class
- While
there may be examples of reasonable reductions in the number of drugs offered
across a given drug class, there are other classes of drugs where reduction in
drugs offered will impede the provision of good medical care. The drug class
for the treatment of substance use disorder (SUD), for example, includes
methadone, buprenorphine, and naltrexone. The elimination of any one of these
drugs from a given formulary would be devastating to the treatment of SUD, as
each drug represents a substantially different approach to treatment that works
particularly well for certain patient populations. A closed formulary that
reduces the offerings in a drug class such that for the treatment of substance
use disorder would have tragic effects of the care provided to MassHealth
beneficiaries. Flexibility must be emphasized to allow for all options in
certain drug classes.
- Exception
process to the formulary must be prompt, accessible
- The
Medical Society appreciates the reference to a critical exception process to
cover drugs medically necessary drugs that are not on the formulary. The
Medical Society urges physician input on the development of this process to
ensure it is does not cause undue delay in care for patients, or additional
administrative burden to physician offices
The
Medical Society also expresses significant concern with the proposal to
establish an independent process to review drugs newly approved by the FDA.
Changes to FDA processes through the 21st Century Cures Act and
other routes were intended to bring drugs to patients in an expedited manner
with assurances of patient safety. FDA approval should not be undermined by
creating a duplicitous approval process in Massachusetts. Instead, new drugs
should be evaluated through the same transparent formulary process, as
addressed above, to determine inclusion into the MassHealth formulary. The
process outlined in the waiver amendment would have disproportionate effects on
certainly disease classes and medical specialties, such as oncology and
infectious disease. The Medical Society believes that all FDA approved drugs
should be evaluated in the same manner, irrespective of the particular FDA
pathway, pursuant to formulary policies that are created with close attention
to the perspectives raised above by the Medical Society.
Narrow Networks in PCC Plan
The
Medical Society is concerned about the proposed changes to narrow the networks
of the traditionally open-networked PCC plan. As mentioned in comments
regarding the original 1115 waiver, the Medical Society appreciates the
administration’s desire to see more patients elect ACO plans. However, such
changes should not come at the expense of patients who choose to retain the PCC
plan, often so that they can retain longstanding relationships with their
primary care physician. Patients should be incented to enroll in ACO plans,
rather than penalized for retaining an existing plan through benefit reductions
and narrowing of networks. Many medically complex patients seek the PCC plan as
the best way to receive optimal medical treatment. Forcing narrow networks as a
way to promote ACOs is not advisable. The Medical Society extends concern about
compliance with Medicaid network adequacy laws, and thus urges the retention of
the current network policies for PCC plans.
The Medical Society appreciates the opportunity to
provide these comments, and looks forward to continuing to partner with the
administration to find strategies that promote sustainability of the program in
manners consistent with the best interests with the patients of the
Commonwealth.
