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Investigative reporting relies upon the effective utilization of information from a variety of sources. Create an Investigative Reporting Outline. Step One: Review the topics below and select one topic for your Final Research Project: Punishment: Prison, Probation, Commutations and Pardons; Law Enforcement; Education; Business: For Profit or Non-Profit; Health Care; Environment. Step Two: Construct an outline that includes the following elements: 1. Discuss a specific issue relevant to the topic you have selected. 2. Distinguish the major players who impact the specific issue you are investigating within the selected topic. 3. Compose two specific questions to pursue for further investigation. 4. Explain two strategies identified by Houston in The Investigative Reporter's Handbook that would assist in the investigation of the selected issue. 5. Select at least one reference each for the topic and for the specific issue you are covering.

Paper For Above Instructions

Selected Topic

Health Care

Specific Issue

Access to affordable prescription medications for low-income seniors and Medicaid beneficiaries — focusing on the interaction between rising drug list prices, insurance coverage gaps, and pharmacy benefit manager (PBM) practices that affect out-of-pocket costs and access.

1. Issue Overview

Prescription drug prices in the United States have risen sharply over the past two decades, creating access and affordability challenges for seniors and low-income Medicaid beneficiaries. High list prices, complex benefit designs, co-payments, and rebate mechanisms administered by PBMs can produce gaps in coverage and high out-of-pocket spending even for insured patients (Kesselheim et al., 2016; Papanicolas et al., 2018). Medicaid programs vary by state in how they cover drugs, apply cost-sharing, and manage preferred drug lists, which leads to geographic inequities in access (KFF, 2023). This investigation will examine how drug pricing mechanics and coverage policies combine to restrict access to essential medicines for vulnerable populations.

2. Major Players

  • Pharmaceutical manufacturers — set list prices and offer rebates; influence availability of patient assistance programs (Kesselheim et al., 2016).
  • Pharmacy Benefit Managers (PBMs) — negotiate rebates and determine formularies; their practices affect both list prices and patient cost-sharing (Brookings, 2019).
  • State Medicaid agencies — design formularies, prior authorization rules, and co-pay policies that shape beneficiary access (KFF, 2023).
  • Centers for Medicare & Medicaid Services (CMS) — federal oversight, Medicaid matching funds, and regulatory guidance (CMS, 2022).
  • Insurers and Medicare Part D plans — determine tiering and cost-sharing that affect seniors (CBO, 2020).
  • Patient advocacy groups and clinicians — represent patient interests and document access barriers (AMA, 2018).
  • Congress and regulators — set statutory frameworks and may enact reforms to pricing and transparency (GAO, 2019).

3. Two Specific Investigative Questions

  1. How do PBM rebate practices and formulary designs used by Medicaid-managed care plans affect the out-of-pocket cost and timely access to high-cost, specialty medications for low-income beneficiaries? (Brookings, 2019)
  2. To what extent do state Medicaid prior authorization policies and step-therapy protocols create measurable delays or denials in treatment for seniors with chronic conditions, and what are the clinical and financial outcomes associated with those delays? (KFF, 2023)

4. Two Houston Strategies and Application

Drawing on strategies outlined by Houston in The Investigative Reporter’s Handbook (Houston, 2009), two particularly useful methods for this investigation are:

a. Public Records and Database Mining

Houston emphasizes systematic use of public records, databases, and procurement files to trace flows of money and policy decisions (Houston, 2009). For this issue, investigators should obtain state Medicaid contracts with managed care organizations and PBMs, formulary and prior authorization policies, pricing and rebate reports where available, and Medicaid drug expenditure data from CMS and state agencies. Analysis of procurement contracts and vendor invoices can reveal rebate arrangements, administrative fees, and incentives that shape formulary placement. Database comparisons across states will identify outlier policies tied to worse access metrics (CMS, 2022; GAO, 2019).

b. Cultivating and Interviewing Sources; Use of Confidential Documents

Houston highlights the importance of cultivating insiders and using documents such as internal memos and emails (Houston, 2009). Interviewing state Medicaid officials, pharmacists, clinicians, and former PBM or plan employees can illuminate how policies are implemented on the ground and yield documents such as internal utilization review guidelines or denial logs. Patient interviews and case studies can document real-world delays and financial harms. Combining source testimony with documentary evidence strengthens claims and helps corroborate systemic patterns (AMA, 2018; Kesselheim et al., 2016).

5. Outline Structure for Reporting

  1. Lead: Concise case study of a Medicaid beneficiary or senior denied timely access to a high-cost medication and the clinical consequences.
  2. Context: National and state-level trends in drug prices and Medicaid drug spending (KFF, 2023; CMS, 2022).
  3. Mechanics: How PBM rebates, formulary tiering, and prior authorization operate (Brookings, 2019; GAO, 2019).
  4. Evidence: Analysis of state Medicaid contracts, denial/prior authorization logs, and comparative data across states showing variation in access and outcomes (state agency documents, Houston strategy applied).
  5. Voices: Interviews with patients, pharmacists, clinicians, state officials, and former industry insiders.
  6. Impact: Quantify delays, denials, and out-of-pocket spending using datasets and case-series.
  7. Solutions: Policy options and reforms to improve affordability and transparency.

References for Topic and Specific Issue

Topic reference (Health Care): Kaiser Family Foundation (KFF) resources on Medicaid and prescription drugs provide comprehensive state-level data and policy analysis (KFF, 2023). Specific-issue reference (Prescription drug access): GAO and peer-reviewed literature document PBM practices, prior authorization impacts, and pricing mechanisms relevant to access (GAO, 2019; Kesselheim et al., 2016).

Investigation Plan and Ethical Considerations

Begin with targeted public-records requests to state Medicaid agencies for contracts, utilization reports, and denial logs. Parallel interviews with affected patients and pharmacists will supply human context. Protect confidentiality for sources who request anonymity and corroborate claims using documentary evidence. Use data-visualization to display state variation and timelines of access delays. Finally, consult clinical experts to assess the medical significance of delayed therapies.

Conclusion

Investigating prescription drug access for low-income seniors and Medicaid beneficiaries requires blending Houston's recommended strategies — exhaustive public-records work and source cultivation — with focused, policy-driven questions about PBM and state Medicaid practices. By pairing case studies with systematic document and data analysis, the investigation can reveal concrete mechanisms that produce access barriers and recommend evidence-based reforms to improve affordability and health outcomes (Houston, 2009; KFF, 2023).

References

  • Houston, B. (2009). The Investigative Reporter's Handbook: A Guide to Documents, Databases, and Techniques (5th ed.). Bedford/St. Martin.
  • Kaiser Family Foundation (KFF). (2023). Medicaid and prescription drug coverage: State variation and policy options. Retrieved from https://www.kff.org
  • Centers for Medicare & Medicaid Services (CMS). (2022). Medicaid drug expenditure trends and data. Retrieved from https://www.cms.gov
  • Government Accountability Office (GAO). (2019). Prescription drugs: Transparency and oversight of drug pricing and PBM practices. GAO Report.
  • Kesselheim, A. S., Avorn, J., & Sarpatwari, A. (2016). The high cost of prescription drugs in the United States: Origins and prospects for reform. JAMA, 316(8), 858–871.
  • Papanicolas, I., Woskie, L. R., & Jha, A. K. (2018). Health care spending in the United States and other high-income countries. New England Journal of Medicine, 378, 1275–1287.
  • Congressional Budget Office (CBO). (2020). Factors affecting prescription drug spending in the federal budget. Retrieved from https://www.cbo.gov
  • IQVIA Institute. (2021). Global medicine spending and trends: The impact of high-cost specialty medicines. IQVIA Report.
  • Brookings Institution. (2019). The role of pharmacy benefit managers in drug pricing: Analysis and implications. Brookings Policy Brief.
  • American Medical Association (AMA). (2018). Prior authorization and its impact on patient care and physician practice. AMA Policy Research.

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