Advocates
for the mentally ill tell the state Department of Human Services that a
preferred drug list limiting medications covered by Medicaid could be
"devastating."
01:00 AM EDT
on Thursday, July 27, 2006BY ELIZABETH GUDRAIS
Journal State House Bureau
PROVIDENCE
-- To save money in the state's Medicaid program by encouraging the use
of less-expensive generic drugs, Rhode Island may be jeopardizing the
health of its mentally ill residents, mental-health advocates say.
The
General Assembly authorized the state Department of Human Services to
create a preferred drug list that would limit the drugs covered by
Medicaid. The DHS sought public feedback on implementing that and other
new laws in a hearing last week. Advocates for the mentally ill
responded in force, pleading with the DHS to exclude mental-illness
medications from the new regulations.
A preferred drug
list could have a "devastating" effect because it would "force
physicians to choose medications that they otherwise would not
prescribe," Chaz Gross, executive director of the National Alliance on
Mental Illness-Rhode Island, said at the hearing.
Providence
resident Charles Feldman said he tried four different antipsychotic
medications before finding one that worked. That drug has enabled him
to hold a job for the last seven years, he said. "Would you prefer that
people like me go back to the hospital . . . and lose their jobs if
they can't get prior authorization for a medication that works?"
Feldman, 54, asked DHS officials.
More than a dozen other states have already enacted preferred drug lists. The lists save money in three ways:
They compel people to use generic drugs when available.
If no generic alternative exists, the list will include the least costly brand-name alternative.
If two or more brand-name alternatives are comparable in cost, a
preferred drug list may still confer savings because all Medicaid
recipients will use one drug, instead of two or more different drugs.
Because Rhode Islanders are buying more of one drug, the state may be
able to negotiate a quantity discount with the drug manufacturer. The
new law also authorizes Rhode Island to participate in multistate pools
to get quantity discounts.
The state budget assumes
implementing the list will save $1.6 million in state general revenues,
and $4.5 million overall -- including federal money -- this fiscal
year, on a program whose annual cost is $27.7 million in state general
revenues, and $58.5 million overall.
The budget article
authorizing the preferred drug list specifically exempts three classes
of drugs: antipsychotics, antiretrovirals and organ-transplant
medications. At the hearing, Gross requested that the state also exempt
antidepressant, antianxiety and anticonvulsive drugs from the new rules.
DHS
Director Ronald A. Lebel says the list, which the department is
developing in conjunction with the University of Rhode Island School of
Pharmacy, will focus first on medications for high blood pressure and
elevated cholesterol levels, and that limiting doctors' and patients'
choice among drugs that treat mental illness isn't a goal.
Another
law change also has mental-health advocates worried: for the first time
this year, those who get prescriptions through Medicaid must pay a
copay -- $1 for each generic, and $3 for each brand-name.
That
may not sound like much, but many people with mental illness require a
treatment regimen of multiple drugs -- commonly between five and eight
prescriptions, testified Elizabeth Earls, president and CEO of the
Rhode Island Council of Community Mental Health Organizations.
The
new rules don't apply to the elderly who get medication through
Medicare Part D drug plans, or to people enrolled in RIte Care, the
state's subsidized health-insurance program for the poor (although RIte
Care is financed in part with federal Medicaid funds). Rather, the
rules apply to about 20,000 low-income Rhode Islanders in the so-called
fee-for-service Medicaid program -- 6,000 children with special
health-care needs, 13,500 disabled adults, and 500 seniors who aren't
eligible for Medicare.
Because preferred drug lists
reduce the overall cost of government, the AARP, which represents the
interests of older Americans, generally supports such lists, said
Barbara Peters, spokeswoman for the AARP of Rhode Island.
Peters
called preferred drug lists "a very good cost-containment tool." But
she said it's important that the lists are based on sound science, and
that the appeal process isn't overly burdensome. "There are cases where
only the brand-name drug will do," Peters said.
The new law says doctors may dispense "72-hour emergency supplies" of drugs "if authorizations cannot be obtained."
It says the DHS will approve a drug not on the list if a doctor can certify that:
The alternative on the preferred drug list "has failed to produce the desired health outcomes."
The patient has tried the alternative on the preferred list and the drug produced "unacceptable side effects."
The patient's condition has responded to a drug not on the list, and changing drugs "would be medically contraindicated."
It
also seems to give doctors the final say. The law says, "If after
consultation with [the DHS], the prescriber, in his or her reasonable
professional judgment, determines that the use of a prescription drug
that is not on the preferred drug list is warranted, the prescriber's
determination shall be final."
Mental-health advocates
still oppose subjecting psychotropic drugs to the list, as does the
pharmaceutical-industry lobby -- which opposes the list altogether.
The
list will clearly cut into drug companies' profits. But it may also
imperil patients' health, said Julie Corcoran, deputy vice president
for state policy with the Pharmaceutical Research and Manufacturers of
America.
"Fundamentally, we believe that all individuals
should have access to all medicine," Corcoran said. "Anything that
interferes with the doctor-patient relationship, we oppose."
