[NYAPRS Enews] SL: States MH Medicaid Cutbacks Hurt Beneficiaries, Other Strategies Recommended to Improve Prescribing Practices

[Harvey Rosenthal]

States Crack Down on Mental Health Prescriptions

by Bara Vaida, Special to Stateline  August 15, 2012

 

In the past two years, Illinois has done just about everything it could
to reduce the amount it spends on prescription drugs for mental health.
It has placed restrictions on the availability of 17 medications used to
treat depression, psychosis and attention-deficit disorder. Doctors now
have to explain to Medicaid why the drugs are necessary before a patient
can get access to them. Then in July, as part of an effort to cut
overall Medicaid spending by $1.6 billion, the state capped the number
of prescriptions for Medicaid recipients to four a month, even if they
previously were taking a broader cocktail of behavioral medications.

 

In financial terms, there is no question that it has worked. Last year,
the state's Medicaid mental health drug spending budget was reduced by
$112 million. The new cap on prescription drugs is expected to save
another $180 million.

 

Up until 2011, behavioral health drug spending made up about a quarter
of Illinois' Medicaid prescription drug costs. The state spent about
$392 million that year on drugs for treating mental health patients. In
fiscal 2012, the state spent $280 million on mental health drugs.

 

But what are the implications for quality of care? Some physicians argue
that they are disastrous. "It's a mess," says Dr. Daniel Yohanna, a
psychiatrist at the University of Chicago Medical Center.  "People who
were stable on some drugs have been unable to get them. It has created a
significant problem."

 

Michael Claffey, of the Illinois Department of Healthcare and Family
Services, says the state is aware of the complaints from the mental
health community, but adds, "we don't have unlimited funds. We need
doctors to work with us...If a patient needs a drug, they will get
approval."

 

Largest Funder

Medicaid is the largest funder of mental health services in the United
States. In 2008, in all 50 states, Medicaid spent a total of $4.5
billion on behavioral health drugs, about a fifth of the $22.5 billion
spent by the program on all pharmaceuticals combined. Roughly a third of
the participants in Medicaid and the Children's Health Insurance Program
experience a mental health episode annually, according to a 2010 report
by the Mental Health Services Administration.

 

The billions spent on mental health drugs have made them a target for
cost containment strategies. All but a handful of state Medicaid
programs have imposed some limits on beneficiaries' access to the drugs.
Oklahoma, for example, started requiring prior authorization for
anti-psychotic drugs, saving the state about $11 million in 2011,
according to a Medicaid spokesman. Vermont saved a smaller sum by
requiring pre-authorization for one anti-psychotic drug that data
suggested had been over prescribed.

 

States have also placed mental health medications on "preferred drug
lists." Manufacturers negotiate with states to get their drugs on those
lists in exchange for giving the state a rebate. State Medicaid programs
have saved an overall $10 billion a year by putting multiple classes of
drugs on preferred lists, according to Vern Smith, a former Michigan
Medicaid director and current managing principal at Health Management
Associates.

 

But controversy remains over the risks of limiting mental health drugs.

 

The American Psychiatric Association suggests that savings achieved by
states on mental health drugs have caused not only a reduction in the
quality of treatment but a spike in spending on other aspects of health
care. Behavioral health drugs work differently on different patients and
some can cause negative side effects, such as dangerous weight gain or
drowsiness. If patients can't get access to a drug that works for them,
or have to try multiple drugs before finding one with few side effects,
they may stop taking their medication. A patient's non-compliance can
sometimes lead to hospitalization or other undesirable results.

 

"It has impacted quality of care, and not in a good way," James H.
Scully Jr., APA's chief executive officer and chief medical officer,
says of Medicaid restrictions. "There is a preponderance of data showing
that patients aren't getting access to their needed medications when
they have lots of hoops to jump through. Without medically indicated
drugs, people with serious mental illnesses are at significant risk for
hospitalization, incarceration, suicide, emergency room visits and other
complications."

 

About half of Medicaid mental health patients had difficulty accessing
at least one medication, and about a quarter of them then stopped taking
their medications, according to a Psychiatric Services report in 2009 on
physicians' experiences in 10 state Medicaid programs. Physicians
reported that many patients experienced an adverse event, such as
hospitalization, homelessness or even suicide because they couldn't get
their drugs.  Another study, reported in the May 2008 issue of Health
Affairs, showed that between 2003 and 2004, Maine's prior authorization
program for atypical antipsychotics (drugs that treat serious psychoses)
resulted in a 29 percent greater risk that patients suffering from
schizophrenia would fail to follow their treatment protocol.

 

Competing studies, on the other hand, suggest that mental health drugs
aren't being properly prescribed, particularly to those under 18, and
that imposing restrictions can improve quality of care by requiring
physicians to reconsider why they are writing a prescription. In 2010,
Rutgers University's Center for Education and Research on Therapeutics
published a study of Medicaid prescribing patterns for children. It
concluded those who were in foster care were more likely to be
prescribed a mental health drug than those who weren't. The study
suggested that prescribing patterns in Medicaid "weren't optimal because
there was over- and under-prescribing," says Sheree Neese-Todd, a senior
program director at the Rutgers Center for Education and Research on
Mental Health Therapeutics.

 

Certainly prior authorization has proved to reduce the number of
prescriptions. In Washington State, where the state implemented prior
authorization and a second opinion program, prescriptions of
antipsychotics to those under 18 have fallen by 50 percent since 2009,
according to Jeff Thompson, chief medical officer of Washington's Health
Care Authority.

 

In Illinois, Yohanna says he has seen examples of inappropriate
prescribing of psychotropic drugs and agrees that "prior approval can
help with that." But he thinks that requiring all doctors to get
approval for drugs "is just throwing a blanket on things without really
dealing with the worst offenders." He says a policy like Washington
State's second opinion program would be a good idea, as well as setting
up a system where there are fewer restrictions on doctors who had
responsible prescribing patterns. Currently Yohanna says, it can take
two to three days to get a drug approved.

 

http://www.pewstates.org/projects/stateline/headlines/states-crack-down-
on-mental-health-prescriptions-85899411084

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