Massachusetts Medical Society: Comment Relative to MassHealth 1115 Demonstration Waiver Amendment

Comment Relative to MassHealth 1115 Demonstration Waiver Amendment

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.

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