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Mental health advocates criticize Medicaid limits on anti-
psychotic meds

by Helen Adamopoulos
April 14, 2011

The Illinois Medicaid agency recently cut costs by moving numerous medications, including several anti-psychotics, to a non-preferred list. Some mental health advocates are saying the agency’s action will come at a high price for people with chronic conditions such as bipolar disorder and schizophrenia. The Illinois Department of Healthcare and Family Services, the state Medicaid agency, maintains a list of preferred and non-preferred prescription drugs for patients, with mostly generics left on the preferred list. Effective April 1, the agency re-categorized a number of medications, including several name brand atypical anti-psychotics, as non-preferred. That means doctors who want to prescribe them to patients on Medicaid will have to obtain prior authorization from the department first. This may result in people with chronic mental disorders not getting the specific medication they need, said Mark Heyrman, a professor at the University of Chicago law school and the facilitator for the Mental Health Summit, a coalition of mental health advocates and providers. As a result of going untreated, they might end up hospitalized or in jail, he said. “This is a real risk for people with mental illnesses,” he said. The anti-psychotics removed from the preferred category include Abilify, Fazaclo, Invega ER, Seroquel and Seroquel XR, according to the list posted on the department’s website. All of these medications are used to treat schizophrenia. Abilify and Seroquel are also used to treat bipolar disorder, according to the National Center for Biotechnology Information. Meryl Sosa, executive director of the Illinois Psychiatric Society, said she heard that the Illinois Department of Human Services expects Medicaid Managed Care to save $800 million during the next five years. The Department of Healthcare and Family Services has a proposed budget of about $14.56 billion for the 2012 fiscal year, said Mike Claffey, a spokesman for the department. That’s compared to $18.5 billion for the current fiscal year. Funds for drugs make up about $2 billion of that amount, and atypical anti-psychotics account for approximately $200 million, he said. Claffey said the average brand name anti-psychotic costs more than $200 per prescription, while the average generic medication costs less than $15. If people currently being treated for serious mental conditions with brand name drugs switch to generic medications, the results could be devastating, Heyrman said. Because the same medication may have a different impact depending on the individual, doctors use a trial and error method to find a drug that works with minimal negative side effects. Once they have found a drug that works, most practitioners wouldn’t recommend switching to another medication, he said. In order to remedy that problem, the department is allowing people who are already on the drugs that have become non-preferred to stay on those medications as long as they have a diagnosis supporting that course of treatment, according to Claffey. “The department is committed to ensuring continuity of care for patients currently on these medications, and for ensuring that patients have timely access to clinically-appropriate medications,” Claffey wrote in an email on behalf of the department. “We have safeguards in place to ensure that patient care is not disrupted.” However, those safeguards won’t help patients who are newly diagnosed, or those who have been off medication for a while and need to start again, said Suzanne Andriukaitis, executive director of the National Alliance on Mental Illness of Greater Chicago. In order to make prior authorization smoother for those people, the department usually reviews requests within two hours of receiving them, Claffey said. They have also agreed to make prior authorization decisions concerning anti-psychotics available within 24 hours and to fax their determinations to doctors rather than mailing a response, Yohanna said. However, Andriukaitis expressed skepticism. “In the past, it has taken sometimes five days,” she said. “If in fact they can turn those decisions around in 24 hours, I will be surprised. Even 24 hours is a long time.” Doctors who write prescriptions for non-preferred drugs will have to remember to tell the patient not to go to the pharmacy for however long it takes to get approval, she said. If the doctor forgets, the patient may try to have the prescription filled and get turned down. If that happens, the person might just decide to go without the medication, she said. “I foresee a lot of stumbling blocks along the way with this new plan, lots of potential times when people could fall of the edge,” she said. Other mental health advocates and doctors don’t see the department’s actions as problematic. Dr. Steve Weinstein is the medical director at Thresholds, an organization and support service on North Ravenswood Avenue that serves people with severe mental illnesses. He said he prescribes medications such as Seroquel on a regular basis, and he doesn’t think the recent changes to the preferred drug list will cause trouble for his patients, particularly because of the grandfathering provision. Weinstein said he uses the prior authorization process five to 10 times per month and hasn’t had difficulties with it. Most of the time, all it takes is a five-minute phone call to get approval. For medications that require paperwork, he said he usually gets authorization within 24 hours. Although he said delays in getting prior authorization may cause “small problems,” he doesn’t agree that people will end up in jail or hospitalized as a result. “That’s unrealistic and dramatic,” Weinstein said. Sosa agreed that the Medicaid agency’s actions won’t necessarily have disastrous results. She said that her organization, a district branch of the American Psychiatric Association, believes people should have access to all behavioral health medications. Still, she said she and other members of her organization understand that the department can’t ignore the financial crisis. “They are in a situation where the state is making them cut costs,” she said. “I don’t think they’re trying to be mean. Hopefully the economic situation will improve, and then they’ll renegotiate it.” Dr. Daniel Yohanna, an associate professor for the University of Chicago department of psychiatry and behavioral neuroscience, said he advised the agency concerning the alterations to the preferred drug list as a member of the Illinois State Medical Society Committee on Drugs and Therapeutics. The committee considered the changes at its March 9 meeting, with the state’s financial crisis spurring the changes, he said. The agency needed to reduce costs as a result of the spending cap enacted as part of the income tax increase legislation in January, he said. According to the state’s official website, the cap limits the state’s spending growth to 2 percent annually for the next four years. Claffey said they are making more changes to the preferred drug list, effective May 2. He said a provider notice regarding these changes will be sent out in the near future, and he will be able to provide more details at that time.


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