Louisiana is a National Leader with their “Prescriber Prevails” Medicaid Policy

BenNeversBen Nevers
State Senator Louisiana

For the past three weeks we’ve devoted this blog to raising awareness around a proposed regulation by the CMS to restrict access to mental health care. But did you know that individual states have fail first policies as well, through the implementation of their Medicaid programs? Read today’s post to learn if your state is on the list.

Louisiana is a National Leader with their “Prescriber Prevails” Medicaid Policy
Keeps access to medication in the hands of physicians and patients

There are many reasons why people do not receive adequate mental health treatment, each of those reasons is as unique and as highly personalized as the individuals themselves. Yet, nearly all stem from the fundamental problem of access. Access to timely, appropriate, affordable mental health care is too often limited and restricted as a result of the following:

  • a shortage of providers or inpatient beds in a given community
  • insurer restrictions on what, when and how providers can prescribe medication and treatment
  • cost barriers that put mental health care financially out of reach

When such barriers obstruct access to care, more people are at risk for serious, disabling mental illness; and in those cases, society bears the related costs. For that reason, I believe we must work together to address these barriers and expand access to mental health services. The cost of not doing so is enormous.

Signs of Progress: Prescriber Prevails

I first introduced mental health parity legislation into the Louisiana State Senate in 2007, and I remain deeply committed to increasing access to mental health services and treatment. I was proud to play a role in the recent passage of legislation in Louisiana that grants Medicaid managed care physicians the authority to prescribe medication they think is most appropriate for their patients, without payer-imposed delay or restrictions.

Why is this important? In many health plans, patients are required to first complete a course of treatment with the least expensive drug, even if that patient’s physician believes a different therapy is most appropriate. These so-called “fail first” and “step-therapy” policies limit a physician’s ability to provide care suited for that patient. The delays can also cause patients’ conditions to deteriorate which, in turn, leads to more intense and costly interventions down the road and increases the risks to patients’ well-being.

As a result of the recently approved Louisiana legislation, patients in the state’s Medicaid managed care programs will now have access to the medication and treatments that their physicians consider most appropriate, and physicians will have an expeditious path around so-called “fail-first” or “step-therapy” protocol. It brings the Medicaid managed care plans in line with commercial plans, and it puts the decision of what is best for patients back in the hands of the physician, where it belongs.

Challenges Remain: Access to Timely Care

In too many communities, budget cuts have led to closure of facilities and reduction of services. According to the Health Resources Services Administration, there are approximately 3,700 federally designated Mental Health Professional Shortage Areas across the country and 107 in my home state alone. That means 89.3 million Americans live in Mental Health Professional Shortage Areas.

In some communities, including those that I represent, the crisis is particularly acute. With the closure of an 18-bed psychiatric unit at a local medical center and the closure of Southeast Louisiana Hospital (the state’s public mental health hospital), access to both in-patient and outpatient services in my district is very limited. It can sometimes take months to get an appointment with a mental health care provider, a delay that can result in a worsening of a person’s condition, more significant health care needs and increased health care costs.

The reduction in services also puts financial strain on our communities in the form of increased use of hospital emergency room services. In many cases, a local police officer will take a person with a mental health issue to our local emergency room because there is no other option for evaluation, treatment and safety. However, this clogs the emergency room and places great financial burden on our health system. The cost of emergency room services is more than 80 times more expensive than the cost of community-based mental health services. As a nation, we can neither afford nor sustain this practice.

Our Call to Action

With the passage of our prescriber prevails legislation last year, I am proud to see Louisiana serving as a leader in the struggle for improved access. People across the country can learn from our success, our remaining challenges, to learn how to address the obstacles to mental health care in their own communities.


  • Become engaged with the legislative process. There are a number of states where prescriber prevails legislation is currently under consideration or stalled. Permitting physicians to proceed with appropriate treatment will, in most cases, result in more effective outcomes in the short term and lower health care expenditures in the long term.
  • Address provider shortages through increased and restored funding. While the full impact of the Affordable Care Act remains to be seen, we do know the surge in demand among the newly insured will place additional strain on our already overburdened system.
  • Talk about mental health issues and make the topic part of our national dialogue. We must move our nation to the place where mental illness is treated the same as diabetes, heart disease, or any other such medical condition. People should demand – and I don’t use that word lightly – that mental health issues be treated just like any other medical condition.
  • Accept that this is not someone else’s issue. We all have a connection to mental health issues, sometimes personally, through a family member or friend, but also through the societal costs we bear. We all share the responsibility to do better.

Your Turn

Proposed changes in Medicare will remove antidepressant and antipsychotic medications from current Provider Prevails policies, but many states have already enacted this barrier with their Medicaid implementation practices.

  • Should state agencies make decisions on the mental health medication patients have access to?
  • What does your state stand on fail first policies?  Does your state protect physician/patient directed treatment?

Facebook Comments

Angela alfaro
Angela alfaro

My name is angla alfaro I have mental problems. I open accounts under others people's information and I treat people like trash, and steel money from others I can't stop using drugs and having sex with strangers. I think about hurting others and myself. I have used a knife on my daughter because she would not give me her weed. My daughter Amanda Lynn paz uses drugs every day. Please help me 7863433323

Katherine Collins
Katherine Collins

Medication choices should always remain in the hands of the patient and provider. "Prescriber prevails" needs to be the message at both state and federal levels regarding Medicaid regulations. To force a patient who is already suffering to start treatment with a medication just because it is the least expensive goes against the ultimate goal of equal access for everyone who suffers from mental illness. We are the wealthiest democracy in the world, with top of the line health care available, yet we restrict and limit peoples' access based on ability to pay. Nothing about that sounds democratic.

William Ashdown
William Ashdown

I am Canadian, so we have slightly different medical and prescribing problems. But we face the same issues. Medications should NEVER be prescribed by dollar, only by how effective they can be. It is infinitely more expensive in the long term to use the cheapest and not the best. having said that, all of medicine needs to take a stand on the appalling cost of most U.S. medications. There are lots of ways to get around high cost, such as group purchases, etc. Beating the dollar problem would make everything else fall into place, and make the U S fall into place behind virtually all the other nations, worldwide. All that is required is the WILL to act.

Stephen Bonin
Stephen Bonin


Your last two sentences launch my opportunity to reveal the results of my investigation today. What I am saying is, last night in my post, I admitted that I wanted to learn more and add today. I interviewed my pharmacist, who has a Ph.D. She is credible in owning a 75-year-old hometown pharmacy and consistently relating to staff and customers with peacefulness and sincerity. Her name is Trina.

Trina helped me realize that Texas is even a stronger example than I was aware of yesterday. She said the sign-up period last Autumn offered 30 formularies. Trina helped customers navigate what was for some a difficult system, for others rather easy.

For example, me, four psych meds and one thyroid med. I am on Medicare, Medicaid secondary. I did not have to make any changes. My cost per med. went up from $1.15 to $1.20. On the other end of the spectrum, Dr. Trina Weideman helped some with combinations of psych and other conditions meds escape some dangerous situations. For example, one lady was on the verge of signing up with a formulary that would have been cost friendly for six months, but then $1,200 per month after that. Did NOT happen. The lady is doiing well with her money and her meds.

So, William, let's continue to work on building positive relationships--personally and professionally. The busy-as-a-beehive U.S. secular broadcast media enjoys sensationalizing and scaring. That's what sells.

Let's all stay open minded, faith- and hope-walking.


Stephen Vincent Bonin

Kimberly Allen
Kimberly Allen

State agencies should not make decisions on the mental health medication patients have access to. Access is the single most critical issue we face. Once again, it is cruel and ineffective to limit access to needed medications. Cost goes up. Care goes down. Would we limit access on heart-related meds and cancer-related medications? The goal is to save lives. If we are able to use generics safely and effectively for some, that is one thing. Most people use a combination of generics and brand-name drugs. The goal is to give appropriate access to care so people get the help they need, when they need it.

Stephen Bonin
Stephen Bonin


Regarding your point that "Access is the single most crucial issue we face," I think you are partly correct. I am adamant about ATTITUDE! We can find help from the federal government, state, regional, local governments also. We can get assistance from churches, neighbors and friends. We MUST have an attitude of calm and assurance. DBSA and NAMI are peer support systems. Psychiatrists will deliver samples free; pharmacists and other entities will deliver a limited supply of meds free to get people through the weekend. As we focus on the reality of ATTITUDE as important along with ACCESS, we find EDUCATION tying in beautifully. We consumers need to be readers! There's BP magazine and Esperanza (Hope for those dealing with Depression and Anxiety). There are a slew of periodicals to scan for mental health updates--such as the current National Geographic, with a cover story on new findings on the brain. There's the magazine Psychology Today, scholarly journals, the internet. I listen to National Public Radio; I watch no television, yet many people do.

Bottom line: let's stay positive and hopeful! Let's build positive relationships, understanding that no one is alone. Everyone must carry burdens, sort through issues.

Let's be sure to exercise, even if it's walking outdoors, where we can smile at people and see and hear wondrous nature, creatures!

Let's get involved in the arts as therapy!

Reading, exeercising, doing arts, eatiing and sleeping well, and limiting time paying attention to inane television shows help us to find enlightenment, surprise, discoveries.


Stephen Bonin
Stephen Bonin

Sen. Nevers' revelation of the accomplishment in Louisiana is heartening. My dad--God rest his soul--was born and reared in south Louisiana, son of sharecroppers. Knowledge of the Broussard area south of Lafayette as an assembly of religious, warm-hearted, jubilant, humble people was one impression. Also, I had visited New Orleans several timess, and experienced the eclectic, the "bipolarity" of that culture with great food.

So, I repeat, I felt happy to read Sen. Nevers' article. His smiling face and trremendously organized, yet easy-to-ingest information, including the link to the map of the United States helped me finally become more familiar with this governmental issue.

I live 60 miles south of Dallas, Texas, in a small city of about 26,000 people. I just came from our weekly DBSA meeting. As we were requested by Phyllis, I did some internet research to learn more about proposed changes to Medicare Part D, and what our state has already in place.

I felt glad to learn that in 2011 a bill was passed which authorizes the physician to prescribe medications that had been approved prior change of rule--prexisting condition, if you will.

This was good news to me.

As you have noticed from my other posts, I was a journalist for many years, refusing to watch t.v. anymore in 2001l, being careful in reading well-rounded sources, understanding the truth of the media as the "4th branch of government."

I continue to encourage us in these posts that situations are always better than what the secular media transmits, because it rides on the fear factor.

I was pleasantly surprised to learn of the 2011 legislation in Texas. I had "known" the stat. that we are 3rd from the bottom of mental health funding. Yet, there's always more to learn.

One of the DBSA members said as part of the change in Medicare Part D, he just received a bill for $2.68 for a med. Not bad at all.

I'm 53--been a consumer long enough to have been with provideres who give samples. Our local mh clinic supported by an awesome, super-networked system with Medicaid, allows my psych. visits for free. This same system, Northstar Value Options, allows my meds.l to be $1.20 each.

We have so much reason to be hopeful. Let us remember to stay positive, and not waste our energy worrying, or getting upset. This same clinic provides flyers for free meds. if someone is out on the weekend.

One more thing. . .a fairly new mhmr clinic that started out last year and a half accommodating substance abusers, is now offering free counseling with Medicaid help. Local. I will meet those folks this week to learn more from them about this Medicare Part D, and what they're doing, and how they feel.

There's always a way.

I need to move on to another project for tonight, but will look forward to having dialogue wih you all tomorrow.

Stephen Vincent Bonin

Denver D. Nobles Jr.
Denver D. Nobles Jr.

Had I not left Washington Parish at 19, I would have never had a life. Due to politics and wages being so low, did not have a papermill job. I should have been diagnosed as a child. My family history had an uncle who was a hobo, whose life is now made him a folk hero. I have found myself as a mental health advocate and have served on many state boards representing mental health. I am currently serving at the NAMI National Consumer Council rep for La., serve currently on NAMILa State Board and NAMI Acadiana Coordinator of Consumer Programs, I find it a little bit comforting to find you taking such a position. 2009 I received the Ken Steele Award, NAMI 2010 Convention Singer/Songwriter, personal story 42 years with bipolar disorder theadvertiser.com reporter Bill Decker, would gladly like to make myself available to you to talk about mental health in Louisiana. At the same time, I would like to ask for your help to get Tombstone for my Uncle Alfred Nobles and my Dad Denver D. Nobles Sr. VA benefits/his Victory Medal of which both served in WWII. Please continue to show your support for mental health.

Stephen Bonin
Stephen Bonin

Denver, your singer/songwriter gift, along with the roles you have served in mental health/mental illness good causes, are examples of the truth that we consumers are intelligent, creative individuals. Thank you for sharing. Stephen