It Doesn’t Add Up

Walker_St LouisNamiDar Walker
Executive Director of NAMI St. Louis

For nine years, Medicare beneficiaries have had access to the antidepressants and antipsychotics that work best for them. Now, a proposed change threatens to revoke that access. The resulting effect will be devastating for individuals with mental illness and their families, and costly to society at large.

It Doesn’t Add Up

Back in 2005, when the Centers for Medicare and Medicaid Services (CMS) launched the Medicare Part D prescription drug benefit, it ensured patients would have unrestricted access to life-saving medicine by granting “protected-class” status to six drug categories, including antidepressants and antipsychotics.

In granting antidepressants and antipsychotics protected-class status, CMS acknowledged that these drugs are chemically distinct and not interchangeable, and patients must have access to the full category of drugs in order to appropriately manage their Illness. In 2010, the unique nature of mental health drugs was reaffirmed when the Affordable Care Act specified that the six protected classes should remain protected.

Yet, CMS is now proposing to revoke protected-class status for antidepressants in 2015 and antipsychotics in 2016. That’s because, according to proposed new criteria, drugs can only have protected status if:

  1. Failure to receive the drug would result in the patient’s hospitalization within seven days, and
  2. Drugs in that class are not interchangeable.

I am not sure how antidepressants and antipsychotics suddenly came to be viewed as interchangeable, particularly given CMS has confirmed multiples times—through its own guidance—that they are not interchangeable. Anyone who battles mental illness or has a loved one with mental illness knows that each person responds to a drug differently, and limiting patients’ access to drugs for mental health treatment will result in deteriorating health for many and increased health-system costs for all.

A game of chance

Part D beneficiaries currently have access to about 57 antidepressants and anti-psychotics; once protected-class status is revoked, that number will shrink to about 15. Those of us who support people with mental illness know that finding the right medication is an imprecise process. Everyone has unique metabolisms, and the same medication will work differently in different people. To limit the antidepressant and antipsychotic formularies is akin to CMS saying it is willing to treat only those patients who are lucky enough to respond to a few, select drugs. Managing mental illness will become a game of chance, rather than a medical science.

My son has schizophrenia, and while he is currently stable, it took us nearly seven years of experimenting with different drugs before we found the right combination of medicine for him. After spending so much time trying to find the best drug treatment for him, to be told he is no longer allowed to use it unless we pay for it out of our own pocket—which would quickly bankrupt our family—would be devastating. That is the position countless beneficiaries will find themselves in if CMS approves the rule change.

Catastrophic response

I came to NAMI St. Louis from an engineering background. In engineering, we sometimes speak of testing to failure. We do this to stress-test systems we plan to use, and while we know our actions will cause significant damage, we proceed anyway so that we can study the resulting destruction and make sure we never push a system to this point in normal operation. This is what CMS is doing with the Part D rule change. There is no mystery as to what will happen should mental health formularies be restricted; we know exactly what will happen, and it is a catastrophic response.

When medication changes are forced upon a large population, those people are subject to destabilization and symptomatic problems. Unfortunately, our mental healthcare system does not have the flexibility to absorb increased demand and, consequently, patients and families will suffer. For example, people who are forced to change medication will require increased supervision as they adjust to a new drug. However, many mental health patients lack access to psychiatric care as it is. Here in Missouri, 114 of our 120 counties have a shortage of psychiatrists and 72 counties have no psychiatrists at all. The increased demand that will result from destabilization will further tax our already overburdened system, and many mental health patients will deteriorate, become isolated, and be forced to survive unsupervised.

A ripple effect

Because our health system will not be able to absorb or manage the expected destabilization, we can expect to see a cascading impact. We will see crisis interventions go up; hospitalization rates will rise; more people will be incarcerated; driven to homelessness and there will be more deaths. In addition, our economy will lose the mind-share of caregivers as they are distracted from their work. It will be a huge inefficiency draw and burden on entire communities and society as a whole.

These are not hypothetical scenarios; we know that this is what happens when people with mental illness are destabilized; and we know that changing medications and limiting access to medications results in destabilization. For CMS to propose, after nine years of saying just the opposite, that antidepressants and antipsychotics are interchangeable is unacceptable; and, in my opinion, borders on criminal negligence foe financial gain.

Join NAMI St. Louis in voicing your opposition to this rule change. Visit our website at for advocacy updates and alerts.

Your Turn

  • Have you ever had to jeopardize your health and go without appropriate medication due to lack of funds to purchase it?
  • How will you support Medicare recipients in retaining their access to quality mental health care?

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