SACRAMENTO, Calif. — The contractor operating California’s new Medicaid prescription drug program has addressed shortfalls that earlier this 12 months left 1000’s of enrollees with out essential medicines, some languishing on maintain for hours as they sought assist, state officers advised lawmakers Thursday.
However medical doctors and well being care clinics say that some sufferers are nonetheless struggling and that the state and its contractor, Magellan Well being, have far more to do.
Michelle Baass, director of the California Division of Well being Care Providers, which administers the state’s Medicaid program, acknowledged the implementation challenges at a legislative price range listening to Thursday. She stated the state intends to carry Magellan accountable for its “poor efficiency” underneath its contract and anticipates withholding roughly two-thirds of its January fee. However she didn’t disclose precisely how a lot that will quantity to.
“Magellan is addressing the decision heart and prior authorization challenges with a surge of recent hiring,” Baass stated. “Name wait occasions have dramatically lowered.”
The state launched its new drug program, generally known as Medi-Cal Rx, on Jan. 1, when Magellan took over administering protection for California’s roughly 14 million Medi-Cal sufferers, most of whom beforehand obtained their medicines by about two dozen managed-care plans. Medi-Cal is California’s Medicaid medical health insurance program for low-income folks.
The transition was imagined to be seamless. However some sufferers have been advised that the prior authorizations they’d obtained for his or her medicines have been not legitimate, and so they have been left with out their medication for days or even weeks whereas they appealed. Others merely gave up attempting to get assist after ready for as much as eight hours on Magellan’s name heart telephone line.
Docs and pharmacists stated a few of their sufferers skilled delays getting lifesaving medicines resembling antibiotics or medication used to stop seizures or blood clots.
Though some suppliers say the delays and wait occasions have improved, a few of their sufferers are nonetheless having issues.
“Possibly enhancements are to return sooner or later,” stated Elizabeth Oseguera, affiliate director of coverage on the California Major Care Affiliation, which represents greater than 1,300 neighborhood well being facilities. “However at this second in time, it’s a trouble, for not solely the employees, however the sufferers who’re having a lot problem in accessing their medicines.”
Well being clinic sufferers are nonetheless struggling to get some medication, Oseguera stated, in addition to specialty medical provides resembling needles utilized by transgender sufferers for hormone injections. When Magellan rejects prescriptions, clinics attempt to discover another drug — a guessing recreation as a result of neither the state nor Magellan has offered an inventory of coated medication and provides that features key particulars resembling permitted producers and doses, Oseguera stated.
Magellan stated it has made “important progress” however that “work is on-going and enhancements will proceed,” in line with a ready assertion that was not attributed to an organization official.
“Magellan and DHCS are dedicated to making sure Medi-Cal beneficiaries obtain the prescribed drugs they want once they want them,” the assertion stated.
KHN reported on the issues plaguing the brand new prescription drug program on Feb. 9. On Thursday, officers with the Division of Well being Care Providers stated Magellan had cleared its backlog of prior authorizations by Feb. 11 and has been reviewing all prior authorization requests inside 24 hours since Feb. 14.
Between Jan. 1 and Feb. 18, Magellan obtained greater than 130,000 requests for prior authorizations, that are required for medicines that medical doctors take into account medically vital however are typically not on the state’s permitted drug listing.
However Magellan couldn’t reply to requests shortly, partially as a result of it was understaffed and unprepared, state officers advised lawmakers in an Meeting price range listening to Feb. 7. Numerous its name heart staff have been sickened throughout the omicron surge, and the corporate didn’t get all the information it wanted from managed-care plans — which slowed the corporate’s opinions of the requests.
In response, the state took a number of emergency actions — resembling eradicating prior authorization necessities for many medicines and giving pharmacists codes to override prescription denials — to cut back the backlog. The state additionally quickly offered staffers to spice up the depleted workforce of the contractor, which reported 100 of its 220 staff absent throughout the first two weeks of the 12 months.
These steps have “dramatically lowered” name wait occasions, and Magellan was answering calls inside 45 seconds on common as of Feb. 22, Baass advised lawmakers Thursday. By the top of February, Magellan expects to have added greater than 120 staffers to its customer support heart and greater than 72 new hires to the prior authorization desk, she stated.
Baass stated there’s now a course of that enrollees and medical doctors can comply with to get assist if they’ve issues getting medicines. Magellan can be establishing a telephone line for sure sufferers with advanced well being wants.
Though the short-term waivers and override codes have helped many Californians get their medicines, physicians fear that such fixes are Band-Aids.
“It’s a short lived repair that’s useful proper now,” Oseguera stated. “As soon as these waivers are lifted, lots of our sufferers might not have the ability to entry their medicines once more.”
State Sen. Richard Pan (D-Sacramento) warned Medi-Cal officers to proceed cautiously. In July, the state is not anticipated to robotically settle for prior authorizations that sufferers had obtained by their managed-care plans.
“It’s vital that if for some motive there isn’t adequate employees in place or different causes, then we have to sluggish the transition,” Pan stated on the listening to. “In order that we don’t depart sufferers hanging like what we noticed originally of January.”