Jumping Over a Dollar to Pick Up a Nickel

david-preciseDavid Precise 
Executive Director of NAMI Louisiana

Jumping Over a Dollar to Pick Up a Nickel
How mental health policies, including the new Medicare Part D proposed rule, sacrifice patient outcomes and long-term cost control for short-term savings

There is an expression I use—jumping over a dollar to pick up a nickel—that describes ignoring one reward in pursuit of another, smaller prize. Blinded by the appeal of the shiny nickel, we ignore the dollar right beneath our feet. Too often, our nation’s mental health policies are driven by such short-sighted mentality; and too frequently, people with mental health disorders suffer as a result.

When the Centers for Medicare and Medicaid Services (CMS) recently announced a Medicare Part D proposed rule, one which would restrict beneficiaries’ access to important antidepressants and antipsychotics, I was disappointed to see yet another example of this reckless mindset. For while restricting formularies is often proposed as a way to control health care costs, we know that denying patients’ access to the full category of drugs often leads to worsening conditions and increased health costs down the road.

That’s because every human being’s brain is different and responds to treatment in different ways. If there are 20 different drugs for schizophrenia and the formulary is cut to just the four cheapest, we put individuals at great risk, and society incurs the associated health costs of untreated and uncontrolled mental illness.

Proving this point, one study by the American Psychiatric Association found that when Medicare patients with mental illness had their medication terminated or interrupted because of formulary changes, many ended up destabilized and in need of costly intervention. Of the patients who had medication-access issues, nearly 20 percent required an emergency room visit and 11 percent required hospitalization. Meanwhile, 3 percent ended up homeless for more than 48 hours.

At a time when national attention is focused on improving mental health care and mental health parity is now literally the law of the land, a rule limiting access to important psychiatric medications is a disappointing set-back. It seems to be the same-old jumping over a dollar to pick up a nickel and I had thought we were progressing past that.

Arming physicians for a fair fight
As executive director of NAMI Louisiana, I work every day to bring attention to the challenges facing people living with mental illness, and I am not naïve about the long road that still lies ahead. One reason the Medicare Part D proposed rule caught me by surprise is that it comes on the heels of opposite policy action here in my home state.

It’s not often that we in Louisiana get to brag about our health successes, but in 2013 our legislature passed a law that removes fail-first requirements from our state’s Medicaid managed care programs. As a result of the new law, physicians in our state’s Medicaid managed care programs have the authority to prescribe medication they think is most appropriate for their patients without payer-imposed restrictions. This means patients will be able to receive appropriate care at the outset, without having to try other, less-effective drugs first.

Arming physicians with the tools they need to manage patients’ care in this way is essential to controlling cost and achieving positive outcomes. And yet, the Medicare Part D proposed rule does just the opposite by crippling physicians’ prescribing authority and limiting patients’ access to care.

In the United States we talk a lot about pride in our military, and rightly so. We invest heavily in our military and we equip our armed forces to do their jobs effectively and efficiently. Wouldn’t it be something if it were the same with mental health care? Imagine what it would be like if we gave our physicians access to every tool they needed to manage patients’ care. Picture what our mental health landscape would like if we entrusted providers to use those tools as they see fit, based on their experience and understanding of each patient’s unique mental health needs.

In the same way that we enable our military to be successful, we must give our physicians the opportunity to treat patients with the full arsenal of options at their disposal.  And that is why we must speak out against the Medicare Part D proposed rule.

Never going to give up
Although it may be frustrating we are having to fight this battle again, we must continue to raise our voices and advocate for access to appropriate, quality mental health care. We must convince our leaders that if we start creating policies that put the patients first, the savings will follow. It will take us continuing to beat the drum and change the conversation so that eventually our policy makers understand that giving people in crisis fewer options is neither medically sound nor cost-effective.

I have no doubt that our community of mental health advocates is ready for this next challenge. I look at your tenacity and resilience over the years and know that you are never going to stop fighting. It’s taken decades to even get this on people’s radar; now that it’s finally here, and mental health parity is literally the law of the land, I believe our momentum will carry us on and we will be on the right side of history. The issue is too important and effects far too many people for us to jump over a dollar in pursuit of a nickel.

Your Turn
Share your story here and with your legislators.

  • How have you or a loved one been affected by restricted formulary?
  • How did having access to several medications make a difference in your or a loved one’s stability?

Visit the NAMI Advocacy Action to send a letter to your U.S. Representative and Senators and ask them to communicate with CMS that they oppose implementation of the Medicare Part D proposed rule.

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10 comments
Care for Your Mind
Care for Your Mind

Right now (Wednesday morning, February 26), the House Energy and Commerce Subcommittee on Health is conducting a hearing to examine the proposed CMS rule that would eliminate antidepressants from the six protected classes under Medicare Part D. Go here to watch: http://energycommerce.house.gov/studio/webcasts. Care For Your Mind is at the hearing, and we're covering it on our Twitter feed @careforyourmind (https://twitter.com/careforyourmind). Watch, comment, and join in on Twitter!

CFYM
CFYM

Happening Now: U.S. Congressional Subcommittee to examine CMS proposed Rule on Protected Classes

As you may know, over the past several weeks, Care For Your Mind has published a number of blog posts discussing the proposed rule issued by the Centers for Medicare and Medicaid Services (CMS) that would eliminate antidepressants from the six protected classes under Medicare Part D. This has been an issue Care For Your Mind has followed closely as it could have a significant impact on the mental health community.

Today, in Washington, beginning at 10 am ET, the House Energy and Commerce Subcommittee on Health will have a hearing to examine the proposed rule. You can view a webcast of the hearing here http://energycommerce.house.gov/studio/webcasts. In addition, Care For Your Mind will be at the hearing and covering it on our Twitter feed @careforyourmind.

We encourage you to watch the hearing, share your thoughts in the comments section, and join the conversation on Twitter.

So Tired of Arguing
So Tired of Arguing

This may surprise folks but many physicians, myself included, are very happy to prescribe a generic that results in a positive outcome for our patients. The patient is satisfied, the out of pocket financial burden is often times inconsequential (though not always -- copays, even those of a few dollars, can become an issue for patients on a limited income and who take many drugs), and we physicians will not be accused (for a moment) of falling prey to a drug company pitch.

Unfortunately, a low cost medication is not the answer for every patient, nor is single drug therapy. And that's when the health system becomes frustrating and punitive to patients and their providers. When my patient has either exhausted the lower cost options or those options aren't suitable, we are both tossed into a lose-lose process. I, along with my office staff, am forced to spend an inordinate amount of time to justify the decision and then subjected to a process often tilted toward no coverage. My patient is often subjected to a similar process that is designed to frustrate and call into question. good evidence based decision making. And that poor patient, for receiving the right drug for them, is subjected to a penalty by way of a copayment that is beyond reach. By the way, the patient will undoubtedly be back in my office for a less than optimal alternative.

I understand and appreciate CMS' stewardship concerns. However, health plans and Pharmacy Benefit Managers are not going to come up with a patient-centered solution as they aren't responsible for patients, only pharmacy program costs. CMS, states, patients, fellow caregivers, we need a better solution.

Lars Lidgren
Lars Lidgren

So you've described a person with an already compromised health condition being subjected to more compromises. I can't imagine this being a situation where two negatives leads to a positive outcome.

Stephen Bonin
Stephen Bonin

Wow! I am so excited to have my eyes opened! In the past two weeks, I have been maintaining that attitude and the slew of well-rounded, wise practices to stay mentally stable will do the job.

Then toward the end of last week I interviewed my pharmacist, whose conviction is the same as this writer's.

He grabbed my attention with the metaphor of overlooking the dollar to save a nickel.

Moreover, he pounded sense into my cognition by comparing the way we build up our military.

This week I will be a stronger advocate per his and my peer colleagues' perspectives.

Stephen

Lars Lidgren
Lars Lidgren

losing ground each day. We have coverage but the drugs we need are unaffordable and beyond our reach. My son's antipsychotic medication's co-pay jumped from $25 in January to $100 this month. A pharmacist from our Blue Cross Blue Shield plan told that me all the branded drugs my son takes (bipolar and diabetes) are now "Tier 4" products and each carry the same $100 monthly co-pay. My son is disabled and can't afford these co-pays; neither can we. And to make matters worse, the least costly alternatives are drugs my son didn't do well on. My kid's being punished for his internist's following the health plan's rules. We've discussed changing our son's meds. No surprise. Alternatives still expensive at $50 monthly co-pays and we now have more doctor visits. IS THERE ANY LOGIC TO THIS?

Stephen Bonin
Stephen Bonin

I emphathize with you. There is no logic. I promise to dedicate my writing time this week to presenting our case to government officials.

Let's stay hopeful!

Stephen

Lars Lidgren
Lars Lidgren

Thanks Stephen, I appreciate your kind words and subsequent actions.

You mentioned interviewing your pharmacist in a subsequent post. Did s/he mention that for many health insurance plans, all branded drugs within the antipsychotic class (and anti-depressants, I checked) are classified as 'non-formulary' and carry the highest monthly co-pays. On our exchange purchased BCBS plan, NOT one branded prescription drug has a co-pay of less than $100/month. My son is eligible for Medicaid because of his disability. However, his drugs aren't covered by IL Medicaid, the process to secure authorization is a nightmare, and finding doctors that accept Medicaid is so difficult. The gentlemen from NAMI Louisiana is so right as to priorities gone astray.

larry drain
larry drain

barbaric idea.

Tennessee has a version of this rule.  Before TennCare (tennessee medicaid) will authorize some medications (read expensive medications) the doctor must get a preauthorization.  What often happens then is that the doctor is told he cannot prescribe the medicine he thinks might work, but must pick from a range of less expensive alternatives regardless of whether or not he thinks it will help his patient.

I have a friend in crisis now because of this rule.  She has struggled with depression most of her life.  On more than one occasion it has been incapacitating.  On more than one occasion she has struggled with suicidal thoughts.  And on more than one occasion she has come close to the act.

They finally found a medication that helped.  Someone once told me that antidepressants dont help but when they do they help a lot.  For her it was a miracle.  And I mean a miracle.  She found an experience of life she had not had in…..well maybe never.

The first 6 weeks she got her medication as samples from the physician.  He told her that he wanted to see if it helped before he wrote a prescription because he knew her insurance had a limited amount of things they would pay for.  He wrote the prescription and my friend went in to pick up the medication.  She was told it needed a preauthorization.  She called the physician.  He told her they had called to get the preauthorization.  She went back to get it.  She was told there was still no preauthorization.  This went on for over 3 weeks back and forth.  The medication was never approved.

After a month the physician was told to stop trying.  They were not going to pay for this medication.  It costs $800 a month, generic is $200 a month and they were not going to pay.  Prescribe something else he was told.

My friend meanwhile is falling apart.  She cant understand why the medication that gave her life is too expensive.  Her desperation and panic has grown each day.  After a life time of struggle, literally a lifetime of struggle hope has been pulled out from under her.

Finally she was told they were prescribing something new.  She went to the pharmacy to get it.  You guessed it.  It needed a preauthorization.

The ambulance took her to the ER last night.  She spent several hours there.  The bill for the ambulance and the ER is far more than the $800.  The harm to her emotionally is without price.  They decided that there was nothing they could do.  They couldn’t help her get the medication.  She didn’t qualify to be hospitalized.  She said she didn’t want to die.  She just wanted help.  In the end she qualified to go home.

Stephen Bonin
Stephen Bonin

Larry,

I feel sad for your friend. I have a high degree of formal education, doctoral level in logic. ( I could not finish the doctorate because of my mental crisis.)

I promise to dedicate emailing time to express the seriousness of our issues to appropriate audiences this week.

Please hang on to hope! Please help your friend participate in positive practices--spiritual, nutritional, physical--that will help her overall strength until the situation is improved.

Stephen