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States Crack Down On Mental Health Prescriptions

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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.

Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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Comments (9 Responses)

  1. Sue Sykes says:

    Illinois mental health services consumers are going to have to start controlling themselves the old-fashioned way: by actually controlling themselves and their behaviors, instead of expecting a pill to do it.

  2. vmgillen says:

    @Sue Sykes: The problem lies more with the people enabling the “consumers” – opting for the easy, psychotropic straightjacket, also known as “Silver Bullet” medicine: the people writing the presciptions. Have you ever been to a clinic, where psychs see a patient for, at most, 15 minutes – that’s only long enough to write an Rx and take enough of a medical history to make sure the specific drug is not glaringly contra-indicated – not enough time to develope a considered and comprehensive treatment plan, certainly. Consider the person who comes in depressed – gets Zoloft – but her depression is caused by an abusive spouse? I think anything that slows the practice of speed-psychiatry, and cuts down the influence of big pharma, is a good thing. On the other hand, your comment seems -hostile? As Dear Abby would say, have you considered seeking help?

  3. cbtambien says:

    @ Sue Sykes, great idea! (Not!) Do you really want to return people who have major psychiatric disorders to dealing with them the old-fashioned way? That will require reopening thousands of psychiatric institutions, hauling out the restraints, setting up the seclusion rooms, and putting in place the locks, the walls, the barbed wire. Also, of course, people lost for years on the back wards. Sorry, NOT a good idea. There are lots of problems with anti-psychotic medications, but they’re not a patch on how we handled mental illness before they were developed.

  4. Miriam says:

    Sue, lose the ableism. Medication for mental illnesses is no different from medication for physical illnesses. In fact, research shows that mental illnesses ARE physical–they affect the structure and function of the brain. Get over yourself.

  5. jb says:

    Excellent comment Sue, your right on the money there, thats for sure. The only problem is, you’ve got a whole big chunk of the community, society, pushing psychiatry’s cart,( the main drug dealers) the pharmaceutical company’s, psychiatrists, and all those employed by mental health, all the drug bunny’s, the compliant, with their own vested interests,and weaknesses, who just wont do the hard work, and properly deal with the crap thats caused their mental problems, you’ve even got psychologists getting on the drug bandwagon as well now, selling us all out, because psychiatry has cut them out with the governments help, and stolen their clients, and cut back on therapy and counseling, so you’ve got all these unevolved people who’d rather take a pill than deal with their problems, and they in turn are getting their kids drugged because “they” as parents, haven’t been able to properly engage with their kids, because they wont, and cant deal with the psychological, behavioral, reasons behind theirs, and their kids problems, and all these people are threatened if you tell them to get real, and deal with their crap, they come back to us and tell us to get real on their poisons, that they even deny are poisons, in spite of some psychotropics having almost 3000 reported and known adverse side effects,I mean thats why they went to a psychiatrist in the first place because they know theyre not strong enough or good enough to deal with the crap, cant even look at it, a pills much easier, anything but look,(- )+(- )= see,find,take advice, try,Stll if someones happy im happy, if someone isnt, and are traumatised by a poisoner, incarcerating them and forcing poison down their throat,with the assistance of a gorilla or two, then im not happy, and i expect you wouldnt be either,sadly though, there are some people, who dont even consider your pain or despair, theyre the type of people who say shut up and open up, your an idiot, an uninsightfull fool.vested only in their own opinions, just like the diagnsois expert, which no matter how you look at it, can only be a subjective opinion at best,yet with one, they can forcefully drug you till the end of time, and do. without a care in the world,adversely debilitated,(reported by them in their truth and honesty) with no known escape, except via the opiniated, so called expert,an affiliate of big pharma,an academically sheltered indoctrinate, who is only accountable to him, or herself.Great little set up there hey, call anyone mad and drug them till the end of time, make big $$$$$$$$$$$$, and no one can change or stop it happening.whether they are drug resistant, not mentally ill, or a high court judge.

    Without consent Electrocuting and poisoning people, but their ok, :), 7 out of ten diagnosis correct statistically, killing one a day in their care,nationally in Australia,how many are being injured then, none according to Miriam,70% taking the poison stay sick, 70% not taking the medication get and stay well, 15 year study,350 people, 1/2 and 1/2,75% of women in mental health facilities report either being sexually accosted or assaulted whilst in the care of that facility,and get this, even though 90%+ are effected by a mind altering substance, and we try to teach poeple that drugs are bad for you,yet the very people teaching us that, psychiatry and mental health, are dealing drugs, with far worse side effects, far more debilitating, back to them. Hello!!! is anybody home?

  6. nroy5775 says:

    I have had to take over a week to get the meds needed for my son. I have had to call Mediciaid, doctors & the pharmasist numerous times to get the info needed to get the medication approved. Some of this has been with his behavior meds & some has been his seizure meds. Both are essentual medication for him. No one shoudl have to go with out their medication for a week or more!

  7. sidney katz says:

    I don’t think the doctor has the right to give medicine or drugs to people with mental heath issues. It’s wrong to do that.At the Hunterdon County Developmental Center, a dr and a nurse gave vitamin D to a member and it made him sick

  8. Charley Huffine, MD says:

    The dilemmas are complex and lets stop offering simplistic answers. Psychiatrists are indeed asked to cramp too much into a 15 min appointment and are not given the time to be true team members with the non-medical therapists in treatment centers. No psychiatrist is going to stay in a job that is abusive to both patient and psycihatrist by design. Ominous restrictions on medications can lead time strapped psychiatrists to mindlessly giving up on certain really helpful medications. Prior authorizations take more time away from the already inadequate amounts of time. Limits on number of medications a patient can have is mindless and could be catastrophic for some patients while others could easily adapt to less medications. Do we want to make such decisions blindly? All this feeds the ignorant antipathy towards any medications. We simply cannot do safe prescribing and thoughtful comprehensive mental health work with our patients without more time and better funding. The costs of scrimping as we are will always lead to higher costs as has been noted; more ER visits, hospitalizations, more jail expenses and how do we ever measure the costs of the loss of a life?

  9. melissa aberg says:

    and how much extra are we paying for all the extra federal employees to take all the extra phone calls and faxes requesting prior authorizations, and then all the extra personnel to process those prior authorizations and make determinations…?
    did we count that into the “savings” we are supposedly getting? I doubt it.
    and if doctors didn’t have to spend so much time getting prior authorizations and with bureaucratic paperwork, and defensive medical practice due to excessive liability, perhaps they could spend more time with each patient and make better medication decisions in the first place.
    just a thought.
    psychiatrists did not “invent” the 5 minute med checks…that was due to government regulations, etc.
    the same government which is now blaming the doctors….convenient.

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