Patient Reported Behaviors in Coping with Medicaid Prescription Caps

Background: Medicaid mandated prescription caps are used as a cost containment strategy in some states. However, for chronically ill, indigent patients, this may prevent these individuals from receiving all needed medications per month.

Objective: A pilot study was conducted to explore how frequently Medicaid patients have to deal with prescription capitation (caps), how patients cope with caps, and how much caps limit access to chronic medications in rural poor communities.

Methods: Questions about experience with the Medicaid cap were included in baseline patient surveys for a medication therapy management (MTM) project. The sample included patients with asthma, diabetes, or a large number of chronic medications who enrolled in the MTM service provided at participating community pharmacies. The questions addressed knowledge of Medicaid coverage of brand and generic products, knowledge of caps, whether patients had reached the monthly cap, and the methods patients used to cope with the cap.

Results: 32 of 83 current participants had Medicaid drug coverage. A majority of the Medicaid patients demonstrated knowledge of the number of prescriptions covered by Medicaid (55%) and the number of branded medications covered (80%). 21(66%) of Medicaid patients had hit the prescription cap at least once in the prior 6 months. Methods for coping with the cap were categorized into three categories: healthcare professional guidance, medication alteration, or payment alteration. Patients were asked to indicate all methods they used to cope with the cap during the last 6 months. Most frequently checked methods were: paying cash for the medication instead of waiting for Medicaid to pay (67%); asking the doctor for samples (57%); waiting until the first of the month for Medicaid to cover the medication (43%); asking to change the prescription (38%); asking a healthcare professional for advice (38%); and going without a medication for one month (38%).

Conclusions: Although prescription caps are intended to control costs from an organization level, it may ultimately be detrimental to patient's health. Patients indicated alternative methods in dealing with caps, including paying out-of-pocket, going without the medication, or asking for samples. These pilot results indicate the problem occurs often enough that a retrospective study using Medicaid and Medicare claims data has been proposed to examine the health outcomes associated with elderly patients reaching the prescription cap. The results also indicate a need for healthcare professionals to provide education and counseling to patients about the best strategies for coping with medication caps.