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?

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