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Hard prescription limits inflate cost, suffering

More than 400,000 adults on TennCare are now limited to no more than five prescription medicines per month. While this arbitrary limit might be OK for most healthy people, it is deadly to many TennCare enrollees who have multiple chronic illnesses.

Right now, they must choose which five they can least afford to do without, and hope for the best. Often, this practice results in worsening medical conditions and hospitalization -- costing TennCare much more than was saved by denying medications.

This “hard prescription limit” policy is both bad medicine and bad management. Commissioner of Finance & Administration Dave Goetz, Former TennCare Director Manny Martins both acknowledged in court that individuals will suffer worsened medical conditions because of limits, ultimately leading to costly hospitalizations. Others have testified that these ``downstream costs’’ of a “hard limit” would be far greater than the financial savings.

In order to prevent this travesty, U.S. District Court Judge John Nixon specifically granted all relief the state said it would need to implement a “soft” drug limit with prior authorization. That means that a patient who needs more than five medicines could get them through a prior authorization system like those commonly found in private-sector health plans.

State officials said they could, and would, institute a “soft limit” within four months. That was in July 2005. Since then, they’ve said they will wait until spring to institute a soft limit. It still has not happened. When asked why they’re not doing it, they blame TennCare advocates, even though there’s nothing in the state’s way.

To their credit, the Administration has formed a “short list” of low-cost prescription drugs – most of them generic – that are exempt from the 5-prescription cap. But frequently, enrollees and their pharmacists don’t know what drugs available through the short list, or don’t know how to make sure they’re not counted against the five-prescription quota.

People are suffering and dying because of the “hard limit.” Some examples:

• Bob B. had to choose which of his medicines to take, and skipped his heart medicine. He suffered a heart attack while on the way to his mailbox. He was taken by air ambulance to the hospital, where he survived. But the air ambulance and hospital stay will cost TennCare at least $100,000 – a cost many times greater than what his heart medicine cost.

• A client called TJC in September, desperate for help because he is a brittle diabetic and had an infection that could result in him losing his foot. He had used his five-prescription allowance, and feared losing his limb for lack of a simple antibiotic.

• Jim B. had multiple chronic health problems, but was limited to five medicines. He died in August, and his death certificate lists his inability to get needed medicines as a contributing factor in his death.

The hard five-prescription limit is both bad medicine and bad management. Bredesen Administration officials have the power to change it.

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