Commentary: States’ Preferred Drug Lists Causing Patients Unnecessary Distress, Pain

Published September 1, 2005

In early August, the Utah legislature’s Executive Appropriations Committee declined to institute a Preferred Drug List policy that would require Medicaid recipients to use drugs on a discount list or go through a prior authorization process.

A few reporters and editors were quick to broadcast their assumption that this decision was driven by political contributions. That assumption is wrong.

States’ PDL Policies Failing

In 2001, the state of Maine implemented a PDL policy–one of the first in the nation. Eight months ago, the MaineCare Advisory Committee’s Prior Authorization Subcommittee submitted to the state Department of Health and Human Services a report, Report and Recommendations on Prior Authorization for Prescription Drugs in the MaineCare and Drugs for the Elderly Programs, that scrutinized Maine’s system and found what it characterized as “disturbing trends.” According to the report:

  • emergency room visits have increased;
  • hospital admissions and patient referrals to specialists have increased;
  • many patients have experienced a worsening of their medical conditions as they jump through hoops to get medications not on the PDL;
  • many patients have been forced to go to the doctor multiple times to get the right medicine;
  • medical staff time and attention have been diverted from patient care to handle “voluminous paperwork” and increased calls from patients;
  • doctors have cut off or are limiting the number of Medicaid patients they accept, because of the increased administrative burden; and
  • quality of care has decreased, with patients suffering painful consequences.

The subcommittee report noted, while a PDL “is an important cost containment tool, aspects of its implementation have adverse consequences directly affecting the health care of thousands.” Other PDL states are also experiencing serious problems.

Problems Develop over Time

I found those concerns to be compelling.

As a taxpayer and legislator, I would like nothing more than to save money in our Medicaid program. The bottom line for me, however, is that I am unwilling to conduct medical experiments on our most vulnerable residents.

Some have asked why we don’t just approve a limited program to see how it would work. The answer is simple. We imagine that we might well save a significant amount of money in the short term, as have Maine and the other PDL states. Short-term savings, however, are only part of the equation.

Let’s look at the dynamics that would be set in motion. A limited program is likely to generate quick positive numbers, while the long-term impact and human cost would remain unquantifiable for several years.

Stories of frustration and tragedy would have a difficult time competing with clear financial data that would build political momentum in favor of PDLs, to the injury of a population that is already striving to overcome immense challenges.

Wrong Time for Experiment

In other words, this train has no brakes. I do not want it to start rolling down the mountain when we know there are people on the tracks below.

Maine is currently investigating the administrative problems caused by its PDL program. At some point in the future, Maine plans to try to quantify the human damage caused by the program to determine if the money it saved was worth the cost.

At this point, I am unwilling to plunge Utah into a similar experiment. Perhaps we can revisit the issue when the bugs are worked out of the PDL system.

Seven legislators on Utah’s Executive Appropriations Committee voted for a Utah PDL; nine voted against it. Each was lobbied fiercely from all sides of the issue. All have their own reasons for the judgment call they had to make. They are all good legislators. They did their job.

You will find your representatives to be far more informed, far more sincere, and more compassionate than the two-dimensional caricatures portrayed by recent media accounts.

John L. Valentine (R-Orem) is president of the Utah State Senate. An earlier version of this article appeared in The Daily Herald (Provo, Utah). Reprinted with permission.