In the ongoing effort to squeeze more juice out of the budget turnip, Alabama’s Medicaid office has revised pharmacy benefits. There are new limits on the number of prescriptions per month for adults, and for all ages, the program will no longer cover any over the counter medications as of October 1.
Were you aware our Medicaid program covered some (not all) OTC medications if prescribed? After all, most private insurances do not, and neither does Medicare. This is an optional coverage by states—we don’t have to do it, and now we won’t.
Most of the OTCs I prescribe for kids are fairly cheap—for instance, 1% hydrocortisone for mild eczema is under $5 a tube. Others are a little pricier—polyethylene glycol for constipation is about $12 to $36 for a one month supply depending on the dose. For most of us, that’s still less than the typical pharmacy co-pay anyway, so what’s the big deal?
You’d be surprised how many families tell me, as they are leaving the office, that they can’t even afford to buy ibuprofen to give their children pain relief, or a thermometer, or a bulb syringe to suction a baby’s nose. Children with Medicaid live at the very lowest income levels, so sometimes there really isn’t $5 or $10 for an OTC medicine. Sometimes, maybe there is—maybe the household budget is out of line and maybe that $5 was spent on something you might judge wasteful or frivolous. The problem for the kids is that whether their parents could budget differently or not, many will simply not get their medications unless Medicaid covers them.
I wasn’t the only pediatrician who thought the change sounded like a problem. Several of us made lists of the most commonly used OTC medications for which there is no good or inexpensive prescription substitute. The list was submitted by an advocacy organization to our Medicaid agency, along with an explanation of our request to have an exception for these limited items. A few days ago we got our answer—no.
We are told this is because of federal rebates for prescription drugs, not available for prescribed OTCs. I understand how that would work in general, but not for everything. 1% hydrocortisone, for instance, can be used sparingly on the face for eczema (along with a thick moisturizer). Stronger prescription steroids are not a great idea on the face for extended use. So our next step up from the $5 OTC is… pimecrolimus or tacrolimus, priced online at $150 or more. I don’t know what Medicaid pays and gets back as a rebate, but I’d be surprised if it isn’t a money loser by comparison to the $5 product.
One of my friends out of state suggested the decision may also be related to Medicaid’s possible switch to Pharmacy Benefit Managers. If we go with third party, for-profit PBMs, they make their profit on our prescriptions and would likely object to any coverage of OTC meds. I’ve asked around and have not been able to find out if PBMs are a factor.
Now I’m going to talk about poop, so if you are eating or squeamish, skip to the end. Pediatricians are bad about poop talk in front of nonmedical people, even at parties.
Constipation is a common problem in babies and children—hard stools that not only hurt but can even tear the anus. I’m talking blood. Children are scared to poop afterwards—they expect pain and they hold back, resulting in more stool buildup and more pain the next time. Eventually, this pain/holding cycle can lead to encopresis—large amounts of hard stool in the now dilated rectum with thinner, liquid stool leaking around it and out into the underwear.
Parents may think their children are not wiping or are having accidents. The kids are embarrassed. It smells bad. They get called names. Whenever I see “train tracks” in a child’s underwear, I know I need to do a rectal exam and see what’s up in there. After diagnosing and explaining the problem, I outline a course of treatment in which we need to get the poop cleaned out and then keep it very soft, like pudding, for several months to avoid new tears and recurrent buildup.
Treatment is almost always successful. OTC polyethylene glycol, PEG, (aka, Miralax is the best thing going for encopresis—both for the initial cleanout and for maintenance. It isn’t absorbed into the body—it pulls water into the stool to soften it. When I was in training, we had mineral oil—a chore to coax children to drink even with heavy flavoring, and there were cases of aspiration pneumonia when the oil got into their lungs. Then we had lactulose—better accepted than mineral oil but not quite as effective as PEG and rarely with significant side effects, including obstruction of the bowel. We had various fiber supplements, which helped inconsistently. For cleanouts, we often had to resort to milk and molasses enemas. Finally we started using PEG. Kids will drink it, it works most of the time, and there are minimal side effects. Life for constipated kids got much better.
Now, depending on the dose needed, families may have to spend as much as $36 a month to keep treatment going. Some will manage to do it, and others will not. Say whatever you want about what the parents “should” do—if it doesn’t happen, it doesn’t happen, and the kid will be the one with a bleeding bottom. Or in the ER for abdominal pain. The number one cause of abdominal pain in children who visit the ER is constipation. Untreated constipation can lead to urinary tract infections. It can lead to CT scans and repeated radiation exposures in the ER. Sometimes we have to admit children for cleanouts, with PEG dripped through a nasogastric tube. I have had kids who got so constipated they vomited fecal material, but not since we’ve been using PEG.
I know some of you by now are asking why we are using medication for constipation at all. Isn’t it a crutch? Why not fix the diet, try juice, prunes, coconut oil, stop all the dairy products, or whatever your favorite home remedy is. We do! If you have been in my office with your child and we haven’t talked about diet, one of us has had memory loss. The problem is sometimes the same as with the cost of the PEG—reality. The children are not buying their own food. And to be fair, some parents really do provide healthy food and the constipation remains.
Whatever your thoughts about how children ought to be eating, when they get painful constipation or encopresis, OTC PEG gets them out of misery. And coverage for it is going away for many of our patients on October 1.
I don’t know if our Medicaid will track ER visits for constipation or complications like UTI to see if costs go up. Will we save money on medications only to spend extra elsewhere? I doubt it will take very long for us to see problems in our practices. I plan to let the state know if I do.
I want the Medicaid money to stretch as far as it can, so that no one goes without needed care. I appreciate the state’s creative efforts to work the budget. This particular change is probably not going to be as bad as the limit on prescriptions for adults, which will land some in the hospital (what do we skip this month—the diabetes medicine, the blood pressure medicine, the heart rhythm medicine?), but it will cause some definite problems. No matter what insurance system we have, even if we had single payer, we would have to think about this type of decision.