Changes to Medi-Cal’s Troubled Drug Program Reduce Backlog in California, but Problems Persist

SACRAMENTO, Calif. — The contractor working California’s new Medicaid prescription drug program has addressed shortfalls that earlier this 12 months left thousands of enrollees without critical medications, 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 Health, have way 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 funds listening to Thursday. She mentioned the state intends to carry Magellan accountable for its “poor efficiency” beneath 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 latest hiring,” Baass mentioned. “Name wait occasions have dramatically decreased.”

The state launched its new drug program, often 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 bought their drugs by way of about two dozen managed-care plans. Medi-Cal is California’s Medicaid medical health insurance program for low-income individuals. 

The transition was speculated to be seamless. However some sufferers have been advised that the prior authorizations they’d acquired for his or her drugs have been now not legitimate, they usually 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.

Medical doctors and pharmacists mentioned a few of their sufferers skilled delays getting lifesaving drugs reminiscent of 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 come back sooner or later,” mentioned Elizabeth Oseguera, affiliate director of coverage on the California Main Care Affiliation, which represents greater than 1,300 neighborhood well being facilities. “However at this second in time, it’s a problem, for not solely the workers, however the sufferers who’re having a lot problem in accessing their drugs.” 

Well being clinic sufferers are nonetheless struggling to get some medication, Oseguera mentioned, in addition to specialty medical provides reminiscent of needles utilized by transgender sufferers for hormone injections. When Magellan rejects prescriptions, clinics attempt to discover another drug — a guessing sport as a result of neither the state nor Magellan has offered a listing of lined medication and provides that features key particulars reminiscent of permitted producers and doses, Oseguera mentioned. 

Magellan mentioned it has made “vital progress” however that “work is on-going and enhancements will proceed,” based on 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 mentioned. 

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 mentioned 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 acquired greater than 130,000 requests for prior authorizations, that are required for drugs that medical doctors take into account medically mandatory however are typically not on the state’s permitted drug record. 

However Magellan couldn’t reply to requests shortly, partly as a result of it was understaffed and unprepared, state officers advised lawmakers in an Meeting funds listening to Feb. 7. Numerous its name heart employees have been sickened in the course of 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 — reminiscent of eradicating prior authorization necessities for many drugs and giving pharmacists codes to override prescription denials — to cut back the backlog. The state additionally briefly offered staffers to spice up the depleted workforce of the contractor, which reported 100 of its 220 workers absent in the course of the first two weeks of the 12 months. 

These steps have “dramatically decreased” name wait occasions, and Magellan was answering calls inside 45 seconds on common as of Feb. 22, Baass advised lawmakers Thursday. By the tip 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 mentioned.

Baass mentioned there may be now a course of that enrollees and medical doctors can observe to get assist if they’ve issues getting drugs. Magellan can also be establishing a telephone line for sure sufferers with complicated well being wants. 

Though the short-term waivers and override codes have helped many Californians get their drugs, physicians fear that such fixes are Band-Aids.

“It’s a short lived repair that’s useful proper now,” Oseguera mentioned. “As soon as these waivers are lifted, lots of our sufferers could not have the ability to entry their drugs once more.” 

State Sen. Richard Pan (D-Sacramento) warned Medi-Cal officers to proceed cautiously. In July, the state is now not anticipated to mechanically settle for prior authorizations that sufferers had obtained by way of their managed-care plans. 

“It’s essential that if for some motive there isn’t adequate workers in place or different causes, then we have to gradual the transition,” Pan mentioned on the listening to. “In order that we don’t go away sufferers hanging like what we noticed originally of January.” 


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