Medicaid patients could face restrictions to access to antipsychotic medications

April 30, 2017 | By Sky Chadde

Longstanding law mandates that people with severe mental illness should face “no restrictions to access” to treatment. Now, lawmakers want to tweak that.

In other states, similar programs that limit access to medications have led to fewer people seeking antipsychotic drugs, studies show. But some Missouri lawmakers argue that the move would save the state money in administering its Medicaid program during a budget bind.

“For us to do nothing in changing how pharmacy is handled in Medicaid is, I think, somewhat irresponsible,” said Rep. David Wood, R-Versailles, who introduced the legislation in the House.

If the legislation is passed — no guarantee with the session winding down to its final days — it would create a preferred drug list for medications that treat mental illness. Doctors would have to prescribe the drugs on that list first.

Patients on Medicaid, which the state helps* pay for, would be able to access drugs that aren’t on the list by having doctors request permission, called “prior authorization.”

Non-antipsychotic drugs are already on a preferred drug list for Medicaid patients in Missouri, Wood said.

Advocates said antipsychotic drugs and drugs that treat heart conditions or injuries shouldn’t be treated the same way. Finding the right medication for an individual with a mental illness might take several attempts, and having to request a waiver to access each drug might interfere with that process, they said.

“Mental illness is different than other illnesses, and the antipsychotics used for the very severe mental illnesses are different than other medications,” said Mark Routburg, who works with the St. Louis chapter of the National Alliance on Mental Illness, at a March committee hearing.

A records custodian for the Missouri Department of Mental Health said the state doesn’t keep track of how many medications patients try before finding one that works for them, making quantifying the scope of the issue difficult.

The original legislation stripped language from the current statute that stipulated there would be “no restrictions to access” to atypical antipsychotic medications, which treat schizophrenia and bipolar disorder.

However, after lobbying from the mental health advocates, the sentence was reinserted in later versions.

If the bill becomes law with that language in it, Wood is concerned that the preferred drug list would be moot.

“It basically wipes it out,” he said. “It makes it totally useless.”

Wood said there will be a push to take the “no restrictions to access” language out of the bill in the session’s final days.

Even with that language included in the legislation, the best option for people with mental illness would be no preferred drug list, said Jacqueline Hudson, the advocacy director for NAMI’s St. Louis branch.

No preferred list has been created yet, Wood said. But the drugs that eventually land on it would, presumably, be among the cheaper options available.

Last year, the state’s Medicaid program, MO HealthNet, spent about $218 million on antipsychotic drugs, according to the state-funded Committee on Legislative Research. The committee estimated the policy change would save the state about $2.6 million a year.

Despite those limited estimated savings, Wood and Sen. David Sater, R-Cassville, who introduced the same legislation in the Senate, maintain that the policy change would actually result in significantly more savings to the state.

Wood pointed to a study from 2009 that estimated a savings of about $27 million in the first year if antipsychotics were placed on a preferred list. The study was conducted by the Lewin Group, which is owned by UnitedHealth Group, one of the largest healthcare insurers in the country.

In other states, there’s evidence that a prior authorization led to fewer people seeking antipsychotic drugs.

A 2008 study in Maine found that the number of people who sought antipsychotic drugs after it instituted prior authorization dropped by about 30 percent.

Also, in 11 states with a prior authorization requirement for Medicaid, the use of antipsychotic drugs rose by 14 percent between 1999 and 2008. In the 19 states without it, use rose by 19 percent, according to a 2011 study.

Wood said these studies were one “perspective.”

“We’re not denying (people with mental illness) anything,” he said of the proposed policy change.

Sater agreed with Wood, saying he didn’t think the same results would happen in Missouri.

“Our program is different from other states,” he said. “We have a very smooth transition in the prior authorization. It usually just takes a matter of seconds to have it approved. It’s very seamless.”

The decision on whether to approve a non-preferred medication happens “instantly” if a prescriber has all the correct information needed for a prior authorization and submits one electronically or requests one on the phone, said Rebecca Woelfel, a Missouri Department of Social Services spokeswoman.

Otherwise, she said, approval or disapproval of the non-preferred drug is required within 24 hours.

In general, the amount of time prior authorization takes depends on the procedure, said Jennifer Coffman, a spokeswoman for University of Missouri Health Care.

For instance, access to radiology treatment can take a few days, but admission for inpatient care can “take up to 24 hours,” she said.

“A timeline” for treatment, she wrote in an email, “depends largely on each individual and what, exactly, he or she needs.”

Mental health advocates worry that adding prior authorization to the treatment of severe mental illness might limit the options readily available to patients, which about 5 percent of the state population has experienced.

“Sometimes hours make a difference” when it comes to effective medication, said Mark Utterback, the president of Mental Health America of Eastern Missouri. “We don’t want any extra steps.”

NAMI’s Hudson agreed.

“We don’t have the luxury of time on our side when we treat people with mental illness,” she said.