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States Organizing a Nonprofit Group to Cut Drug Costs

By MILT FREUDENHEIM, NY Times

 January 14, 2003

In the strongest challenge yet in the battle between the states and the manufacturers and distributors of prescription drugs, nine states and the District of Columbia are organizing a joint nonprofit operation to manage their prescription plans, officials in charge of the effort said yesterday.  

The states intend to hold down spending on medicines for millions of state employees and Medicaid beneficiaries by creating an organization designed to be immune to drug makers' promotions of many of their more expensive products.  

The new organization is being formed at a time when two-thirds of the states are reducing Medicaid coverage, restricting eligibility or ending benefits altogether for at least one million people. A study by the Kaiser Family Foundation issued yesterday said state Medicaid directors expected further cuts in benefits and eligibility.  

Dozens of states are facing their largest deficits in years. Their combined shortfall for the current fiscal year is estimated at $45 billion, and the deficit for next year is projected to increase sharply, reaching 20 percent or more in some states.  

Health care spending is a major part of the financial problems the states face, and drugs are the fastest growing component.  

New York, for example, spent $2.4 billion on prescription drugs for more than 3 million Medicaid recipients in 2001, 7.5 percent of all its Medicaid spending and an increase of 75 percent from 1998.  

"New York has the most to gain," from the new organization, said Peter E. Shumlin, chairman of the National Legislative Association on Prescription Drug Prices, the group that is organizing the new benefit plan. Mr. Shumlin, a former Vermont state senator, said New York "is doing the least of all the states" in his group to hold down drug spending.  

The new drug benefit manager will try to help New York and the other eight states — Maine, Massachusetts, Connecticut, Rhode Island, Vermont, New Hampshire, Pennsylvania and Hawaii — maximize the drug benefits they can provide given their current budget constraints.  

Drug benefits for the state employees and Medicaid recipients in most of those states are currently managed by private companies called pharmacy benefit managers. Under their current contracts, these drug plan managers pocket sizable undisclosed payments, known as rebates, from drug makers in return for promoting certain drugs. They then create lists of drugs, called formularies, for different ailments and often set prices that induce drug plan members to opt for the drugs that have been promoted.  

At least three of the largest drug benefit managers, Medco Health Solutions, AdvancePCS, and Express Scripts, have special deals with drug manufacturers that require them to create financial incentives for Medicaid recipients to use certain prescription drugs, many of them quite expensive.  

By managing their drug benefit programs themselves, the states intend to keep any drug company payments for themselves. They plan to use medical experts to help them determine the most cost effective and appropriate drugs to offer, often supplanting the ones promoted most heavily by drug makers.  

The states also plan to ask their attorneys general to review the fine print on their existing prescription drug contracts to make sure that programs for low-income and uninsured residents receive the full benefit of price discounts already negotiated with drug makers.  

State consumer fraud and antitrust investigators in New York, Connecticut, Maine and several other states are already examining existing state contracts with Medco, AdvancePCS, Express Scripts and other pharmacy benefit management companies that provide drug benefits for 200 million Americans.  

The new drug benefit manager will compete with private pharmacy benefit managers, all of them creating lists of drugs at attractive prices. That way, the states sponsoring the new organization will have a choice of lists of preferred drugs at discounted prices, said Mr. Shumlin of the National Legislative Association.  

Other states have created programs to try to rein in their prescription drug costs. Michigan has tried to use the federal Medicaid law as leverage to force drug manufacturers and wholesalers to sell their products in the state at discounted prices. Maine offered Medicaid program discounts to people who did not qualify for Medicaid, and Florida obtained extra rebates from manufacturers. Drug companies have challenged the plans in court, with varying results.  

Some states, including New York, have never had a preferred drug list for Medicare recipients. Richard N. Gottfried, chairman of the New York State Assembly health committee and a member of the legislative association planning group for the new drug plan manager, said the state could generate "enormous savings" by selecting a list of preferred drugs and obtaining discounts for Medicaid and other health care programs for women and children.  

The organizers say the new nonprofit plan would include coverage for mail-order prescriptions and for importing drugs from Canada, where the government keeps prices low. American drug manufacturers and a New York state pharmacy group have objected to previous state efforts to import prescription drugs from Canada. GlaxoSmithKline warned on Friday that it would stop supplying drugs to Canadian enterprises that ship them to the United States.  

Bruce Lott, a spokesman for the Pharmaceutical Research and Manufacturers of America, a trade group, said his group opposed any program that would buy drugs for a pool that included both Medicaid and non-Medicaid plan members like state employees. "The Medicaid program already receives the manufacturers' best price, and the Medicaid program and Medicaid patients would not benefit from inclusion in such a pool," he said.  

The Heinz Family Philanthropies, a charitable group, is paying for planning for the nine-state plan. Jeffrey Lewis, executive director of the foundation, said the states hoped to farm out most of the operations, like processing payment claims and selecting networks of pharmacies.  

Cheryl Rivers, executive director of the National Legislative Association, said the new organization would develop its preferred drug list itself to guard against undisclosed behind-the-scenes arrangements that could benefit drug manufacturers.  

She said the mere existence of the new plan would lead to better pricing from commercial pharmacy benefit managers. "We are already starting to see some of that," she said.  

The big pharmacy benefit managers said they would welcome new competition. "We always look forward to competing," said Steve Littlejohn, a spokesman for Express Scripts. The states "can make informed decisions in selecting the plan that makes most sense for them."

Dale Thomas, a spokesman for Advance, said, "AdvancePCS views any efforts to organize a coalition using the tools of the P.B.M. model as yet another validation of the industry's success."


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