Medication Dispensing and Medicaid Managed Care

To the Editor.—We read with cautious optimism the article by Dr Epstein¹ on Medicaid managed care and quality of care. As physicians in the Community Health Network (the safety net delivery system of San Francisco, Calif), we have witnessed some of the positive and negative effects of the evolution in health care that he described. We have numerous practical concerns about quality of care that are not being addressed by the state. For example, with regard to pharmacy benefits, the state has avoided taking a stance on the policy of health plans to authorize no more than a 1-month supply of medications to enrollees. The health plans are concerned with the negative fiscal impact dispensing medications to ineligible patients would have on their bottom line (15% of patients in San Francisco either change plans or become ineligible on a monthly basis). The plans would rather pay the monthly pharmacy dispensing fee ($2.25) 3 times, than dispense a 3-month supply of medications at 1 time, since months 2 and 3 are potential losses.