In 2007, Utah lawmakers passed legislation creating a Medicaid preferred drug list, or PDL, hoping to save about $8 million a year by encouraging doctors to prescribe less expensive medications. Last year, the Utah Department of Health learned it had actually underestimated those savings -- by over 300 percent. In fiscal 2011, the state realized $27.6 million in drug cost reductions. That’s without including psychotropic drugs, such as antipsychotics and antidepressants, which Utah state Sen. Allen Christensen says account for more than one-third of the Medicaid medication budget.
“There’s room for so much more savings,” he said when the numbers were released, and to that effect he introduced new legislation to create a PDL for psychotropic drugs. Utah is one of only a handful of states that still allow nearly unrestricted access to these medications. That will change if Christensen’s bill passes, which raises a difficult question: Are patients at risk if access to these drugs is limited?
Mental health advocates say yes, because these drugs are different from other drugs. “Mental illness is not like other diseases, such as high cholesterol, where generally one class of drugs works for most people,” says Sarah M. Steverman, director of state policy for Mental Health America (formerly the National Mental Health Association). “Here it often takes doctors time to figure out what works, what combinations work and how to control the side effects, which can be very bad. In some ways, it’s an art as well as a science.”
Christensen says his bill includes grandfathering, emergency overrides and other provisions that ensure no one will be denied the drug they need. But his bill also requires that there be scientific evidence to prove the nonpreferred drug is important. He points to the success of the established PDL and asks, “Are mental health drugs more important than anti-cancer drugs or heart drugs? Those are life-and-death drugs. Are people dying?”
They can, mental health advocates respond. High blood pressure doesn’t lead to suicide, but depression can. Asthma isn’t linked to homelessness or criminality, but schizophrenia has been. Therefore, they say, savings generated in the psychotropic pharmacy budget line would be offset by increases in other social and medical costs as a result of patients not getting the proper medicine and care.
A 2009 study in Psychiatric Services, the journal of the American Psychiatric Association, found that gaps in medication therapy not only lead to increased hospitalization, crisis intervention and violence -- all paid for by the state -- they also increase the odds for homelessness by three times and double the odds of incarceration or detention in prison or jail. “All of these cost more than just treating them would have,” Steverman says.
This debate isn’t unique to just Utah. A number of groups, including Mental Health America, continually work with states that already have some kind of psychotropic PDL, because pharmaceutical and therapeutic committees continually revise the lists and state legislatures tinker with the laws. “It’s a churning, a constant dialogue,” says Michael Fitzpatrick, executive director of the National Alliance on Mental Illness (NAMI).
A former Maine state legislator, Fitzpatrick recognizes the tough position states are in. “We understand tight budgets and the need to cut in this economy,” he says. That’s why NAMI and other groups suggest other ways to cut costs.
“We support programs that promote cost-efficiency through better care coordination and prescribing patterns, moving toward a health home model and payment negotiation,” Fitzpatrick says. “There are alternative approaches, and states need to be very careful about simply limiting access. The outcomes are just devastating.”