Four years ago, staff at Wyoming’s Medicaid program noticed a dramatic spike in the use of a medication that can lower the risk of serious lung illnesses in children.
The drug, Synagis, was costing the state more in Medicaid dollars than all but one other medication. Officials wanted to know why.
Synagis is used for children who are at high risk of developing serious complications from respiratory syncytial virus, or RSV, a common viral infection. Medicaid data showed some physicians were prescribing the drug to children who were not at great risk of developing severe lung infections. Other doctors were providing it year-round, even though the RSV season only lasts about five months.
“When we looked at it, a lot of the docs were not giving it in accordance with the recommendations,” said Wyoming Medicaid’s medical director, Dr. James Bush.
Health officials devised a plan. Medicaid would no longer automatically reimburse doctors who prescribed Synagis. Instead, doctors had to provide a justification for prescribing the drug. Approval would be automatic if they followed national guidelines, but Bush would review requests that deviated from the recommendations.
The results were dramatic. The number of doses administered by doctors decreased 64 percent. Annual spending on Synagis dropped from $2.5 million to $1 million, according to the Wyoming Department of Health.
“It basically made them stop and take a look,” Bush said.
The savings come as state officials work to curb the rise in Medicaid spending. The program, which provides care to the poor and medically needy, is expected to cost Wyoming more than half a billion dollars during the state’s current two-year budget cycle.
“We didn’t want to hurt anyone,” Bush said. “But if we could save the state a significant amount of money, that is money we can spend in other areas where we can make a difference.”
Health officials tracked Medicaid data to determine whether the change affected patients. Last month, they completed an analysis of nearly seven years’ worth of Medicaid data and found the authorization requirement did not result in a significant increase in RSV-related cases or hospitalizations.
“There was no detriment to our patients because of this,” Bush said. “We didn’t do any harm and we saved the state $1.5 million a year.”
The change did cause some hassles at first, said Dr. Bob Prentice, a pediatrician at Cheyenne Children’s Clinic. It meant more paperwork, which could take 30 to 45 minutes for nurses to complete.
Those delays have largely gone away as medical providers get used to the new system.
“Now we know what the paperwork looks like, we know what questions they’re going to ask,” Prentice said. “It doesn’t take any longer than of the other drugs we pre-authorize.”
Medicaid officials have also been flexible in cases where the physician feels a patient should receive the drug outside the recommended guidelines, Prentice added. Bush personally reviews such requests.
“Nothing exactly fits the rules and they’ve been willing to work with us,” Prentice said.
State health officials are examining other ways to curb spending within the Medicaid program. They are paying particular attention to assessing the quality of care that’s provided to patients, Bush said. “We have many irons in the fire,” he said.