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RX- Antipsychotic Medication Use In Medicaid-Insured Children Decreased Substantially Between 2008 And 2016

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


[MM Curator Summary]: Celebrating that now only 55% of Medicaid kids getting a powerful antipsychotic med are missing a relevant diagnosis to validate they need it or suggest are getting their care managed.



Clipped from:


After the rapid growth of pediatric antipsychotic prescribing in the early 2000s, especially in the Medicaid population, concerns regarding the safety and appropriateness of such prescribing increased. Many states implemented policy and educational initiatives aimed at safer and more judicious antipsychotic use. Antipsychotic use leveled off in the late 2000s, but there have been no recent national estimates of trends in antipsychotic use in children enrolled in Medicaid, and it is unclear how use varied by race and ethnicity. This study observed a sizable decline in antipsychotic use among children ages 2–17 between 2008 and 2016. Although the magnitude of change varied, declines were observed across foster care status, age, sex, and racial and ethnic groups studied. The proportion of children with an antipsychotic prescription who received any diagnosis associated with a pediatric indication that was approved by the Food and Drug Administration increased from 38 percent in 2008 to 45 percent in 2016, which may indicate a trend toward more judicious prescribing.





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Posted on

RX- 340 B Medicaid MCO Duplicate Discount Confusion and HHS

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


[MM Curator Summary]: MCOs will have to add a field to the drug claims they manage under proposed CMS rules. The new field will make it easier for manufacturers to not get dinged having to offer discounts on drugs twice.



Clipped from:

On May 26, 2023, the Centers for Medicare and Medicaid Services (CMS) proposed an update to the Medicaid Drug Rebate Program (MDRP) rules, which includes provisions aimed at preventing 340B duplicate discounts on claims billed to Medicaid managed care organizations (MCOs). Duplicate discounts arise when both 340B discounts and Medicaid rebates are provided by a manufacturer for the same drug. Although drug manufacturers that participate in Medicaid are required to provide discounts on 340B drugs under the 340B Drug Pricing Program and are also required to provide state Medicaid programs with rebates under the MDRP on drugs dispensed to Medicaid beneficiaries, including Medicaid MCO enrollees, manufacturers are not required to provide both a 340B discount and a Medicaid rebate under the MDRP for the same drug.


Because the relevant statutory provisions do not clearly articulate whether the state Medicaid program, the Medicaid MCO or the 340B-participating provider (covered entity) is responsible for ensuring that duplicate discounts do not occur for Medicaid MCO claims, there currently is no uniform system for identifying Medicaid MCO claims for 340B drugs. In the years since Medicaid MCO drugs became eligible for rebates under the MDRP, the US Department of Health and Human Services (HHS) has generally encouraged the relevant stakeholders and affected parties to work together to develop a solution. To date, that has not occurred. It appears that HHS may finally be stepping in to develop, or at least work towards, a solution.

Under the proposed rule, CMS would modify the standard Medicaid MCO contract requirements to require Medicaid MCOs that provide coverage of covered outpatient drugs to use unique, Medicaid-specific codes and group numbers on beneficiary insurance cards. The use of these identifiers would assist state Medicaid programs, MCOs and 340B covered entities to identify Medicaid MCO claims that might not otherwise be readily apparent as Medicaid MCO claims. Currently it is not uncommon for Medicaid MCOs to use the same group identifiers as claims for patients with private insurance. If implemented as proposed, the various stakeholders could more efficiently develop additional tools to identify such claims as being for 340B drugs or to exclude such claims for being filled using 340B drugs. CMS indicated that this change would allow the MDRP to run more efficiently, and would be helpful to all parties by ensuring that Medicaid rebates and 340B discounts are being provided appropriately. CMS proposed that this new requirement be implemented into Medicaid MCO contracts no later than the next rating period, following the effective date of the final rule adopting this provision.

While the proposed rule would provide an important tool to assist in the development of additional policies to prevent duplicate discounts on Medicaid MCO claims, it would not itself effectuate a full solution. The proposed rule also does not address the ongoing concern among 340B covered entities that state Medicaid programs or Medicaid MCOs could expand 340B “carve out” requirements or reduce reimbursement rates on 340B drugs dispensed to Medicaid MCO enrollees, thereby removing the opportunity for 340B covered entities to obtain the benefit that Congress intended for them to receive through the 340B Program—i.e., generating revenue from 340B drug sales to enable 340B covered entities to provide and expand services in their communities.

CMS solicited comments on the proposed change by July 25, 2023, and specifically requested comments regarding the implementation timeframe and operational issues that may arise from requiring the inclusion of unique Medicaid identifiers on Medicaid MCO beneficiary identification cards.

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Safety-net providers sue to stop Medicaid carveout


MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


[MM Curator Summary]: Facilities that make lots of money off the 340B scam are now resorting to “equity” as their last defense against the long-planned reform in NY.



Clipped from:


03/27/2023 10:00 AM EDT

Presented by HANYS and GNYHA

Beat Memo

Two safety-net providers are taking the state Health Department to court in a last-ditch effort to prevent a disputed Medicaid carveout from taking effect.

Evergreen Health, along with Heritage Health and Housing, a not-for-profit that operates a federally qualified health center in Harlem, filed a lawsuit in New York Supreme Court on Friday seeking an injunction of the carveout before it takes effect April 1.

They allege the long-planned effort to merge Medicaid pharmacy benefits under a single state program violates federal law and is discriminatory.

The litigation escalates an ongoing battle at the eleventh hour over the proposed change to how millions of New Yorkers will soon access their medication. The plan, a remnant of Gov. Andrew Cuomo’s last fiscal budget proposal, in 2021, could potentially save the state hundreds of millions of dollars, according to Gov. Kathy Hochul’s proposed budget.

But fierce opposition, mainly from safety-net providers who financially depend on a decades-old federal program known as 340B, which would be sidelined under the new rules, stalled the reform for years.

At a budget hearing in late February to discuss the carveout, Housing Works CEO Charles King was one of several protesters arrested on trespassing charges after disrupting the proceedings to oppose the measure.

New York City Mayor
Eric Adams and Ashwin Vasan, the city’s health commissioner, have also come out against the carveout, saying it would disproportionately harm LGBTQ patients and patients living with HIV.

“DOH will wreak immeasurable harm upon New York’s safety-net health care providers and the largely low-income persons dependent upon those providers for their health care and medications,” the complaint says.

Supporters of the program, including the Pharmacists Society of the State of New York, say that community pharmacies need it to survive, and that the change would allow patients greater access to choose where they get their medications.

The New York State Health Department did not immediately respond to a request for comment on Sunday.


— No one spoke up for or against proposed rate changes to ambulance fees in New York City at a public hearing Friday, leading FDNY officials to close the hearing early. The changes, which were first reported by POLITICO, would raise the cost of basic life-support ambulance services to $1,385 from $900. They would also charge patients $20 per mile traveled rather than $15, among a few other hikes.

The new fee schedule would ultimately bring in more than $16 millions in revenue for the city in fiscal year 2024, an FDNY spokesperson told POLITICO in February. It is expected to go into effect in the spring.

In a written statement to the FDNY, David Jones and Stephen Krause, the president and executive vice president of the nonprofit Community Service Society, opposed the new fee schedule, saying it would have the “unintended consequence of compelling New Yorkers to forgo medically necessary ambulance services to avoid the prospect of a large bill.”


Tuesday at 10:30 a.m. — The Cannabis Association of New York will hold a press conference as it lobbies lawmakers in Albany.

Thursday at 10 a.m. — The New York City Council’s Health Committee will hold an oversight hearing on improving access to in-community and at-home health care.

GOT TIPS? Send story ideas and feedback to Maya Kaufman at

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Odds and ends

NOW WE KNOW — Having trouble sleeping? You might live in the wrong city.

TODAY’S TIP — Could the causes of eczema be in the air we breathe?

STUDY THIS — The use of certain hormonal birth control methods may be associated with a 20-30 percent increased risk of breast cancer, according to researchers at Oxford.

What We’re Reading

— Patients on the drug aripiprazole should be better informed about the risks of gambling addiction, The Guardian reports.

— Via the Huffington Post: The Ozempic craze has pushed people in eating disorder recovery a step closer to relapsing.

— U.S. life expectancy remains on the decline relative to other countries.

— Cannabis use at older ages can carry special risks. Read what they are.

— The first signs of Alzheimer’s might be in your eyes, new research suggests.

— Via The New York Times: “Philadelphia tells residents to consider bottled water after chemical spill”


Florida is using a little-known law to punish abortion clinics, reports Arek Sarkissian.

MISSED A ROUNDUP? Get caught up on the New York Health Care Newsletter.

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Posted on

RX- Another Voice: Medicaid pharmacy program reform is greatly needed


MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


[MM Curator Summary]: An op-ed in favor of reforming how NY Medicaid pays for Medicaid drugs.




Clipped from:

SUBSCRIBE: $1 for 3 months

New York is reforming its Medicaid pharmacy program to remove managed care and pharmacy benefit managers (PBMs) and directly administer these benefits for enrollees. This change cannot come soon enough.

Health insurance plans and PBMs are paid to administer the pharmacy program and patients are required to participate in one of 16 managed plans. They can only use pharmacies in the PBM network. Patients are precluded from using a pharmacy that may be in their neighborhood or close to their place of work.

When a managed care plan in Ticonderoga recently dropped one of the only two pharmacies in the area from its network, patients were unable to obtain needed medications. We must do better than having the state pay financially motivated corporations to make business decisions that disrupt and restrict patient access to needed care.

Plans have their own drug formulary. Medicaid enrollees can only use drugs on the plan formulary, which means that what may be covered for one patient may not be covered for another. The current system also imposes significant administrative burdens on prescribers to comply with the complex maze of plan requirements, protocols, processes and paperwork in order to help our patients get the drug coverage they need and deserve. Every day, physicians deal with plan and PBM denials, delays and rejections that waste their time and delay patient access to treatment.

Come April 1, News York State will launch the New York State Medicaid pharmacy program known as NYRx. It will provide one formulary covering all FDA-approved medications. NYRx has one set of rules for prescribers and will provide better access to lifesaving therapies for Medicaid patients.

The New York State Academy of Family Physicians was the first medical society in New York to advocate for a single payer system of universal health. We see the state’s decision to launch NYRx as a first and transformative step toward reform of health care in New York.

Absent enactment of single payer legislation, the academy has advocated for streamlining and standardizing health coverage to reduce administrative burdens and make health care easier to access for patients and for those who care for them. NYRx will simplify the pharmacy benefit for all with Medicaid. Patients will not be limited by pharmacy network requirements and varying plan requirements and processes. Also, removal of for-profit health plans and PBMs from this benefit will save money that can be applied to Medicaid coverage and patient services.

Health plans, PBMs and others oppose NYRx. The governor and Legislature must resist these efforts. New Yorkers with Medicaid need a simplified and standardized pharmacy benefit directly administered by New York State, as was the case a decade ago. NYRx is a model for the much broader system reforms we continue to advocate for to benefit all New Yorkers.

Dr. Andrew Symons, of Tonawanda, is president of the New York State Academy of Family Physicians.

Posted on

RX- Medicaid commission calls for flexibility in drug coverage

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


[MM Curator Summary]: MEDPAC thinks Medicaid programs should be able to have their own rx coverage process other than “well I guess if it made it through the p*ss poor FDA process, we have to pay for it.”


Clipped from:

Illustration: Megan Robinson/Axios

The Medicaid and CHIP Payment and Access Commission voted Friday to ask Congress to let states restrict Medicaid coverage of a drug when Medicare only covers it in clinical trials and while other data is collected on effectiveness.

Why it matters: Unlike Medicare, Medicaid has to fully cover FDA approved drugs regardless of their cost or how much real-world evidence exists on the drug’s effectiveness — which has the potential to wreak havoc on state budgets.

  • The commission wants Congress to level the playing field between Medicaid and other insurers and give states the option for more flexibility.

Reality check: Lawmakers on both sides of the aisle support making it harder for Medicare to limit coverage of FDA-approved drugs — so it would be an uphill battle to get Congress to expand the coverage pathway to Medicaid.

  • Regardless, the vote indicates this is a difficult issue that Medicaid stakeholders aren’t likely to drop anytime soon.

Driving the news: Last year, regulators decided Medicare will cover the controversial Alzheimer’s drug Aduhelm only for patients enrolled in randomized clinical trials.

  • The National Association of Medicaid Directors said in a February letter that limiting Medicare coverage would shift costs onto state Medicaid programs, since Medicaid programs don’t have the same option to restrict coverage.

Giving Medicaid the ability to cover drugs only in clinical trial settings could take some financial pressure off of states to cover expensive but questionably effective drugs, according to MACPAC.

  • The policy could also encourage drug manufacturers to move through traditional FDA approval and show adequate clinical benefit, the commission said.


  • But MACPAC noted during Thursday’s meeting that limiting Medicaid coverage of drugs can reduce beneficiaries’ access to therapeutics and create more administrative work for prescribing providers.

What they’re saying: “To me, the key issue here is that we’re talking about medications that have potential benefit, but we don’t actually know if it’s an actual benefit yet,” MACPAC Commissioner Angelo Giardino said during the commission’s Thursday meeting.

  • Commissioner Heidi Allen was the lone member to vote against the recommendation.
  • “I think [this flexibility] has equity and access implications, and it’s hard for us to look into the future to say what those would be,” Allen, a social work professor at Columbia University, said during the Thursday meeting.
Posted on

Rx- Nebraska Medicaid officials seek $16 million a year for new Alzheimer’s drug


MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


[MM Curator Summary]: The state is asking for more for this one drug than for its entire I/DD waiting list.


Nebraska officials are predicting that a controversial new Alzheimer’s drug could drive up state Medicaid costs by more than $16 million annually.

That includes the cost of the drug, Aduhelm, plus monthly intravenous infusions used to deliver the drug and the regular laboratory tests and brain scans needed to monitor its effects.

The cost of covering Aduhelm is among several issues listed in the Department of Health and Human Services budget request for the two-year period ending June 30, 2025. The submission of agency budget requests to the Governor’s Office kicked off the months-long process of crafting a new state budget.

While the $16 million request pales in comparison to the $2.5 billion annual cost of Nebraska Medicaid, the budget impact would be larger than the $15 million requested for the first year of HHS salary increases or the $11.9 million requested to serve 250 Nebraskans with developmental disabilities on the state’s waiting list.

According to the HHS request, state tax dollars would cover nearly $7 million of the cost, with the remaining $9 million coming from federal funds.

The federal Food and Drug Administration approved Aduhelm, the brand name for aducanumab, in June 2021. The drug is the first new Alzheimer’s drug approved in two decades and the first of a class of medications targeting the amyloid plaques that develop in the brains of Alzheimer’s patients.

The decision proved immediately controversial. Clinical trials showed that the drug reduced amyloid in the brain, which the FDA said is reasonably likely to slow the progression of the disease in Alzheimer’s patients.

“This could mean more time for individuals to actively participate in daily life, have sustained independence and hold on to memories longer,” said Angel Horton Frank, a spokeswoman for the Alzheimer’s Association of Nebraska.

Critics said the drug showed only mixed benefits in clinical trials leading up to the FDA decision, despite an initial price tag of $56,000 a year. Biogen, the drug’s manufacturer, has since cut the cost to about $28,200 a year. Critics also pointed out that the drug was approved through an accelerated FDA process.

In January, the Centers for Medicare and Medicaid Services announced that Medicare would cover Aduhelm only for people who get it through a clinical trial. That decision came as several private insurers announced that they would not cover the drug, labeling it experimental.

Federal law, however, requires Medicaid programs to cover nearly all FDA-approved drugs. As a result, the decision to sharply limit Medicare coverage of Aduhelm means the full cost of the drug and associated care will fall on Medicaid for qualifying patients.

Medicare is a federal health program for people 65 and older or with disabilities. Medicaid is a state-federal program for low-income people. For low-income seniors, Medicaid pays what Medicare does not.

Frank, the state Alzheimer’s Association spokeswoman, said the organization believes Medicaid should cover aducanumab.

“Americans living with Alzheimer’s disease are entitled to access FDA-approved therapies, just as are people with conditions like cancer, heart disease and HIV/AIDS,” she said.

The Alzheimer’s Association estimates that more than 35,000 people in Nebraska have Alzheimer’s or dementia, out of some 6 million people nationwide.

It’s unclear whether anyone in Nebraska has started using the drug. Nationally, doctors have been reluctant to prescribe it.

Frank referred that question to Dr. Daniel Murman, director of the University of Nebraska Medical Center’s memory disorders and behavioral neurology program. He said he has no patients getting the drug currently because of its cost and the lack of insurance coverage.

But he said the medical center will be part of a clinical trial of Aduhelm for people at early stages of the disease, making it possible for participants to qualify for Medicare coverage.

Murman expressed hope about the potential for drugs like aducanumab. Just this week, drugmakers Eisai and Biogen reported that a medication called lecanemab had slowed clinical decline in Alzheimer’s patients by 27% in clinical trials when compared with a placebo. Similar drugs are in varying stages of development.

“I am optimistic that this treatment approach will be an important breakthrough in the treatment of patients with Alzheimer’s disease who are at the earliest stages of their disease and if clinical benefits are confirmed, then this class of medications should be covered by Medicaid and other payers,” Murman said.

Myzette Howell discusses the process of caregiving for her parents Loretta and Percy Howell, who have diagnosed with Alzheimer’s Disease.


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