Medication restrictions burden patients and clinicians

As states grapple with increasing prescription drug costs in their Medicaid plans, many have begun to employ utilization management techniques, like fail-first strategies or restricted formularies, to cap costs. But such restrictions on mental health medications in Medicaid are adversely affecting patient outcomes and increasing administrative costs for community mental health providers, according to a new survey conducted by the National Council for Behavioral Health and the National Alliance on Mental Illness (NAMI).

In Illinois, for example, the state placed restrictions on 17 psychiatric medications and in 2013, capped the number of all prescriptions for Medicaid recipients to four per month without prior approval. More than a dozen other states have similar script limits, although some exempt psychiatric medications.

However, it’s not clear that this strategy is actually reducing overall costs.

“It’s difficult to quantify long-term costs when people are not adhering to treatment, and utilizing high cost services like jails and emergency rooms,” says Andrew Sperling, director of federal legislative advocacy for NAMI. “In Medicare Part D, where we have broad access protection in place, we have not seen costs explode.”

Mental health prescriptions account for a significant chunk of the rapid growth in Medicaid prescription costs (as much as 40 percent or more, according to some estimates), which is why states are targeting those drugs. According to the National Association of State Budget Officers’ Fiscal 2014 report, five states took budget action to limit prescription drugs within Medicaid last year, and another 11 states had pursued other efforts to reduce such costs. For 2015, those numbers were three and nine, respectively.

And it’s not just Medicaid. Commercial plans and health-insurance-exchange plans have also implemented formulary controls that target psychiatric medications. Prescription benefit management (PBM) services are similarly placing limits on everything from high-priced cancer drugs to hepatitis-C treatments.

Barriers to access

Patients can be adversely affected by policies that limit use of prescribed medications, or require providers to use step therapy approaches (also called “fail first”) because of logistics. Three-quarters of respondents to the National Council survey said that patients had trouble complying with their medication plans, and 62 percent said patients experienced increased emergency department visits, hospitalizations and healthcare costs.

“When patients are faced with these barriers, they are far less likely to adhere to their ideal medication regimen,” says Rebecca Farley, director of policy and advocacy at the National Council. “That leads to all sorts of negative outcomes, like increased hospitalizations. Our psychiatrists also indicated that they see higher rates of incarceration, and that’s a cost that could potentially be avoided if people had access to treatment at the right time.”

That means that although many states have implemented these policies to reduce the rapidly rising cost of medications for their own budgets, they are likely increasing administrative costs for providers and other secondary costs. According to the Journal of the American Board of Family Medicine (January-February 2013), primary care doctors spend $3,430 in labor costs related to prior authorization tasks in a single year.

"Why do you need to spend 45 minutes on the phone to get a prior authorization on a generic antidepressant?”

“The physician should have full range of access to drugs without question. The problem is that most of these restrictions are not evidence-based; they are cost-based,” says Sam Muszynski, director of the American Psychiatric Association’s office of healthcare systems and financing. “The amount of uncompensated time required to get a simple prior authorization even on generic drugs is absolutely insane. Why do you need to spend 45 minutes on the phone to get a prior authorization on a generic antidepressant?”

Cutting into treatment time

The most common obstacles that state plans have put in place are prior authorizations, preferred drug lists, limitations on the number of prescriptions a patient can access, or fail-first/step therapy requirements. All of these can influence how psychiatrists approach treatment.

“It changes how psychiatrists decide what medications to prescribe,” says Ruth Shim, one of the authors of the survey. “You have to think twice about prescribing the medication you think will work the best, because of the prior authorization process that might go along with the medication.”

The provider survey examined how these restrictions are affecting patient outcomes, based on responses from National Council-affiliated psychiatrists in community mental health centers.

More than one-third of respondents reported that they spent between 11 percent and 20 percent of their time handling tasks related to prior authorizations. One in 10 reported spending 40 percent or more of their time on utilization management-related tasks. Since available drugs have variable levels of tolerability depending on the patient, and some patients might try multiple meds before finding a good fit, doctors could spend more time on drug approvals than actual treatment.

“As a clinician, I know these barriers get in the way of being able to practice,” says Shim, who is with the Department of Psychology at New York City’s Lenox Hill Hospital. “There’s a lot of faxing, filling out paperwork, and re-appealing.”

Providers who have several patients that need that kind of attention can end up spending a good bit of their day getting approvals—actions that they don’t recieve reimbursement for.

“What the new research shows is how much these polices are getting in the way of psychiatrists practicing medicine in the way they view as most appropriate,” Farley adds. “It’s important to understand how much time psychiatrists spend on administrative issues related to utilization, which takes time away from caring for patients. With a shortage of psychiatrists in this country, the last thing we need is to pull them into these administrative tasks that don’t improve patient health.”

It also increases costs for mental health services providers, which can drive psychiatrists out of Medicaid, state exchange, and private insurance plans.

“You have to hire new people to deal with all of this stuff,” Muszynski says. “At some point you throw up your arms and decide you can’t afford it. You can’t make it up in volume when one of the numbers is negative.”

Cost shifting

Previous studies on mental health prescription restrictions have found that they negatively affect patient outcomes, and don’t generate the expected cost savings because those costs are shifted to other modes of care. A recent study (Forum for Health Economics and Policy, September 2014) from researchers at the University of Southern California looked at patient outcomes and spending from 24 state Medicaid programs from 2001 to 2008 and found that restricting access to antidepressants increased the probability of a related hospitalization by 1.7 percentage points, and resulted in zero net savings for Medicaid.

Another study from Harvard Medical School in 2008 (Health Affairs, May 2008) looked at the effect of Maine’s prior authorization policies to control the use of atypical antipsychotics. Patients initiating the medications after the policy was implemented experienced a 29 percent higher risk of treatment discontinuity than patients who did so before the policy, with little cost savings ($2.33 per patient, per month). However, treatment discontinuities identified in the study were strongly associated with increased risk of hospitalization, which would actually increase costs.

Effectiveness studies needed

In addition to state-level efforts to restrict medications, there are also federal and industry initiatives to limit the use of psychotropic medications among certain patient populations, such as in nursing homes or youth in foster care. These efforts are getting intermingled with cost-control measures at the state level to justify prescription restrictions in some cases.

In Kansas, for example, current law prohibits the state from using these types of restrictions to manage the use and cost of mental health prescriptions for Medicaid recipients. However, the state legislature’s KanCare Oversight Committee has recommended repealing that law. Outgoing Republican state representative David Crum, former co-chair of the committee, said that the limits would not apply to patients with “persistent, chronic mental illness,” a threshold not currently defined in the law. Crum specifically cited the misuse of the drugs with elderly patients as a reason to increase controls. Clinical protocol indicates that elderly dementia patients, for example, should not be treated with antipsychotic medication.

But advocates say that the issue at the state level remains cost, not off-label use of anti-psychotics and other drugs.

“Placing limitations on drugs in order to prevent problematic prescribing of those drugs doesn’t serve people who are using the medications for legitimate purposes to stay in good health,” Farley says. “There are a whole host of other things that should be done to address problematic uses of mediation. Utilization management restrictions harm people who need those medications to live a healthy and functioning life in recovery.”

One potential fix would be application of more comparative effectiveness studies by clinicians, advocacy groups, and lawmakers.

“I think we’re a little behind on where the evidence is in implementing some of these things,” Shim says. “I don’t think we’ve consistently applied new evidence to formulary restrictions. We need to create a more effective feedback loop so that evidence is translated into regular police decisions around medications in a more rapid fashion.”

According to Muszynski, it’s incumbent on the field to develop evidence-based guidelines on appropriate prescribing practices, so clinicians have something to rely on to make payers accountable.

There are unintended clinical consequences to any utilization-management strategies health plans put on medications, says Muszynski.

“And nobody’s accountable for that,” he says. “They’re not measuring patient outcomes at the same time.”

Any effort to roll back restrictions would have to be done at the state level, however, because of the way Medicaid benefits are structured. In the meantime, clinicians can expect to see an increasing number of hoops to jump through when it comes to psychiatric prescriptions.

Brian Albright is a freelance writer based in Columbus, Ohio.

More Online: See the National Council survey here https://bit.ly/1AR0YBQ