Almost 30 million Americans live with asthma, including five million children. For many of them, the right medication makes the difference between a life fully lived and one punctuated by frequent medical emergencies. State regulators now play a role in whether Medicaid patients can access those treatments.
Severe and complex forms of asthma require treatment far more advanced than standard rescue inhalers, and promising medicines are available. Biologic therapies target specific immune pathways associated with severe asthma, offering relief to patients for whom no other treatment is available. States’ preferred drug lists should include all clinically appropriate treatment options, promoting individualized treatment and better patient outcomes.
The High Cost of Excluding Treatments
Preferred drug lists guide which medications are covered by Medicaid, the publicly funded health care program for low-income individuals. If those lists exclude cutting-edge technologies like biologics for severe asthma, patients may be unable to access those treatments even when recommended by a doctor. A patient living with severe asthma is increasingly likely to encounter an insurance exclusion that can delay or deny a critical prescription.
Attempts to manage Medicaid care and costs, including prior authorization requests, have morphed into barriers that exclude those with fewer resources. Patients denied treatment can file appeals or requests for exceptions, but many of them never do. A high percentage of appeals succeed, casting doubt on whether the delays and discouragement are a necessary part of the process. Excluding treatments from Medicaid formularies, even if every appeal succeeds, generates significant costs.
Formulary exclusions have tangible costs:
- Avoidable emergency department visits and hospitalizations
- Patients compelled to use ineffective treatments while conditions worsen
- Added administrative burden, burnout and wasted time in physicians’ offices
- Increased overhead and financial risk for small practices and independent pharmacies
- Lower patient satisfaction and abandonment of care
For both patient outcomes and Medicaid’s bottom line, states should invest in treating severe asthma with the best available treatment. Uncontrolled disease can create costly complications later and contribute to lost workplace productivity from asthma symptoms.
Modernizing Medicaid Coverage for Severe Asthma
Access to a wide range of treatment options is a key component of personalized medicine, tailored to each patient’s unique needs. When some treatments, perhaps the most suitable, are unavailable to those with public insurance, those patients receive inferior care. Medicaid coverage should not be written to exclude those patients from the evolving professional standard for treating conditions like asthma. Low-income or low-mobility patients and children are more vulnerable to asthma symptoms and bureaucratic barriers to care.
There are opportunities for patients and advocates to engage directly with Medicaid programs. Entities like pharmacy and therapeutics committees establish the state’s preferred drug list, while drug utilization review boards determine the utilization management strategies that will be used. In most states, there are ample opportunities for patients to ensure their perspective is heard and the value of different treatment options are heard by state Medicaid officials. Incorporating patient and clinician perspectives is key to ensuring legislation acts on behalf of patients.
