Care For Your Mind acknowledges and appreciates the collaboration of the National Network of Depression Centers and the American Association for Geriatric Psychiatry in developing this post.
Putting Profits Over Patients: Medicare Part D Changes Mean Disaster for People with Depression
Daniel D. Sewell, MD, Director, Senior Behavioral Health, UC San Diego Medical Center
In older adults, depression can have severe consequences. It’s associated with an increased risk of suicide; decreased physical, cognitive and social functioning; and greater self-neglect; all of which are associated with increased mortality. This is a vulnerable population that needs effective, affordable access to mental health care.
Unfortunately, proposed changes to the Medicare Part D drug program would put older patients living with depression at even greater risk.
The Medicare Payment Advisory Commission (MedPAC), an influential independent agency advising Congress on Medicare spending, has issued a report recommending that antidepressants lose their protected status under Medicare Part D. What this means is that insurance companies would be authorized to restrict formulary coverage of FDA-approved antidepressants. This proposed coverage limitation would be in addition to already existing Part D benefit limitations, e.g., step therapy, prior authorization, and higher patient co-payments.
Proponents argue that this change would allow insurance companies to negotiate lower drug prices, thus lowering premiums and prices for the consumer. But is it truly realistic to expect that profit-driven insurance companies will pass any cost savings on to enrollees? This has never happened in the past, why would it happen now? Instead, beneficiaries will see real-life consequences if their medication coverage is cut further.
Given that the current system already tends to overlook the mental health needs of older adults, these changes would further erode effective coverage and fundamentally handicap the ability of physicians to care properly for their patients. MedPAC’s report is flawed, and patients, physicians, and advocates need to stand up and oppose its recommendations.
What’s on the table
The Centers for Medicare & Medicaid Services (CMS) first proposed removing antidepressants’ protected status in 2014. Many advocacy groups — including my colleagues at the American Association for Geriatric Psychiatry (AAGP) — came together to oppose the proposal, fearing that such a change would limit access to vital therapies for older adults with mental health issues.
The 2014 plan was tabled, but MedPAC’s June 2016 report to Congress has raised these same ideas yet again. The current report, however, carries erroneous assumptions regarding clinical practice that would cause serious problems when it comes to on-the-ground patient care.
For one thing, Part D plans would be permitted to limit coverage of antidepressants to only two options in any given category. These drugs, however, are not interchangeable; putting such strict limitations on medication choices would hurt patients who have responded to, or whose individual circumstances require, a particular medication.
Take SSRIs, for example. As the most common form of antidepressant, there are six or seven drugs in this category. But the side effects and drug efficacy for each medication differs for patients due to their unique biochemistry and physiology.
In addition, MedPAC’s recommendations as to limiting covered antidepressants don’t reflect the complex needs of older patients. The SSRI paroxetine, for example, is not preferred for older adults because it has the highest degree of intrinsic anticholinergic properties among all of the SSRIs. Experts generally recommend that medications that are highly anticholinergic should be avoided in older adults whenever possible to avoid the potential of severe side effects. In addition, because many seniors take multiple prescriptions, paroxetine’s high potential for drug interactions is of concern. This kind of consideration is insufficiently weighted by MedPAC and proponents of further limiting physician and patient choice of therapy.
Limiting drugs will lead to higher costs
It’s no secret that insurance companies tend to favor older drugs with generic substitutes, given that they’re cheaper. But newer, more refined drugs are often better for older patients who are more sensitive to side effects. Based on MedPAC’s recommendations, insurers could cut out the newer drugs and only cover the older cheaper ones. But this is a shortsighted idea that ignores the long-term costs for patients and the system itself.
Many older patients live on limited incomes and already struggle to pay for their out-of-pocket healthcare costs. For them, $10 or $15 for a 30-day supply of generic antidepressant may be a large sum, particularly difficult to absorb if the antidepressant is ineffective. Expecting these patients to pay out-of-pocket for the full cost of any non-covered (brand name or generic) drug often isn’t an option—even if that drug is the best choice for them. In such cases, if I prescribe some other antidepressant that is preferred under the plan’s formulary, then the patient may be compromising on their quality of treatment.
In the end, because of the potential result of ineffective treatment efforts, these consequences could prove more expensive to the system than the original medication. It’s penny-wise and pound foolish, not to mention cruel.
Wasting doctors’ time is bad for everyone
The MedPAC report suggests that if a provider feels strongly about a patient remaining on a particular medication, the doctor could submit documentation (orally or in writing) that would allow for that medicine to be maintained. But who pays the physician for time spent corresponding with an insurance company?
Personally, I cringe when I have to engage an insurance plan about a drug. I often spend 15 to 30 minutes waiting to talk to a live person, then I’m interrogated about my rationale for the medication exception — all while I have a roomful of patients waiting to be seen. These phone calls have to be made during business hours, which means I’m taking time away from my patients and practice, thus decreasing my productivity. Alternatively, I may be directed to a website with a required form that must be completed. These forms vary in their design and ease of use and in the end, the time spent completing these forms is not associated with payment and also decreases time that could be spent with patients.
These are real concerns for psychiatrists who are already pressed for time and forced into already too short 15-minute appointment slots with patients.
These recommendations also ignore the input of the most important person involved: the patient. When a medication choice is made, it’s based in part on the patient’s needs, values, and preferences. Ideally, doctors and patients discuss these factors in a process known as shared decision-making (SDM). This is one of three pieces of the prescribing puzzle: when we make drug decisions, we rely on our own clinical expertise as physicians, the best available scientific evidence, AND the patient’s unique perspective.
Clearly, patient-centeredness is not a consideration in these recommendations. Although the MedPAC report implies that the insurance companies are flexible about medication choice, the reality is that they’re anything but.
In addition, doctors already face the mind-boggling task of keeping track of which drugs are covered under what insurance plans. I probably deal with 8 or 10 different plans in my region. Based on these recommendations, insurance companies could submit mid-year changes to coverage; if preferred antidepressants changed every six months for each plan, there’s no way I could keep up.
We need to stand up for older adults
All of these potential financial and human costs could be avoided if antidepressants retain their protected status under Medicare Part D. Changing what’s available could be devastating for patients, and there’s a naiveté in these proposed changes that doesn’t reflect life in the trenches.
Just like in 2014, these changes are a bad idea. Amid a healthcare culture that already tends to overlook older adults, removing antidepressants from the protected class would further decrease quality of care. Aren’t we aiming for just the opposite?
Patients need access to drugs that improve their lives … not drugs that are a better deal for the insurance companies.
Your Turn
- What consequences to you foresee to people you care about if antidepressant medications are further restricted under Medicare Part D?
- What do you think Congress should do with MedPAC’s recommendation to reduce the number of covered antidepressants?
Bio
Daniel D. Sewell, MD, is a Professor of Clinical Psychiatry in the Department of Psychiatry UC San Diego. Dr. Sewell currently fills a number of roles at UC San Diego which include: Medical Director of the Senior Behavioral Health Program, Director Emeritus of the Geropsychiatry Fellowship Program, Co-director of the Memory Aging and Resilience Clinic, and Course Director for the fourth-year medical student geropsychiatry elective. Dr. Sewell’s honors, awards and contributions to the field include: being named a “Top Doc” in San Diego County for the past 5 years in a row, receiving the UC San Diego Leonard Tow 2005 Humanism in Medicine Award; being recognized as a Distinguished Fellow of the American Psychiatric Association; serving as the ACROSS Representative for the American Association for Geriatric Psychiatry in the American Psychiatric Association’s Assembly, serving as a member of the Board of Directors of the American Association for Geriatric Psychiatry, 2010-2013; receiving the 2014 American Association for Geriatric Psychiatry Educator of the Year Award and being voted the Recipient, of the UC San Diego School of Medicine’s Third Year Class 2016 Kaiser Excellence in Teaching Award. In addition, Dr. Sewell is currently serving as the president of the American Association for Geriatric Psychiatry and has authored over four dozen peer-reviewed scientific publications.
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