Penny-Wise but Pound-Foolish: Medicaid Denies Resistance Tests
Have you heard this one? Joe complains to his doctor about a sore throat so bad that he can’t swallow. The doc confirms that the throat looks sore, then gives the patient some pills to take. “Will they help my throat, doctor?” Joe asks. “Don’t know,” the MD replies. “They worked for another patient last week.”
Not funny? Gee, we don’t think so, either. It’s hyperbole, of course, but that’s almost how Texas Medicaid asks physicians to prescribe treatment for HIV-positive patients.
Some patients who previously responded well to the “drug cocktail” find their virus rebounding because it has become resistant to one or more of the drugs in their particular combination. HIV-experienced physicians bring skill and knowledge to choosing a replacement combination, but it is still largely guesswork. It doesn’t have to be: there are tests to show which drugs will work and which won’t, but Texas Medicaid won’t pay for them. Resistance testing is today regarded as the standard of care, and 45 states cover it; Texas joins Mississippi among the five that don’t.
Resistance testing isn’t cheap — the frequently preferred genotype test runs $300-$500 — but when the drugs themselves cost $1,000 per month or more, it pays to be using the right ones. The potential benefit in reduced human suffering — priceless.
As the Legislature’s committees explore the issues facing the 2003 session, making sure that Texas Medicaid follows U.S. Department of Health and Human Services treatment guidelines should be near the top of the health-care list. Whether they adopt genotype or phenotype testing or both is not critical, but some form of resistance test needs to be provided. Too much money and too many lives are at stake.
This article appears in June 7 • 2002.