Speaking Up For the Silent Majority

Scott-ArbaughDr. Scott Arbaugh
Faculty Member Washington University
Director, Geriatric Day Treatment Programs
Alton Memorial Hospital (Alton, IL), St. Joseph’s Hospital (Highland, IL) and St. Joseph’s Hospital (Breese, IL)

Today’s CFYM post, illustrates the struggles seniors are having obtaining appropriate medication. Click here to provide a comment to CMS and ask them to rescind their proposed regulation restricting access to antidepressant and antipsychotic medications. The deadline for entering comments is this Friday, March 7, 2014 so please act today and make your voice heard!

Speaking Up For the Silent Majority
How the proposed changes to Medicare Part D will harm middle-class seniors

As a geriatric psychiatrist in private practice, I see many middle-class patients. These are folks who have worked hard their whole lives and saved for their retirement; their homes and cars are paid for and they have a few dollars in the bank. Medicare covers the bulk of their healthcare expenses and many can afford some level of supplemental coverage.

This is not the population we’re used to seeing in crisis. Yet more and more, these are the people who are going without appropriate mental health medication and, as a result, facing destabilization and serious mental health challenges. That’s because for the first time in my 25 years of practice, I’m seeing middle-class seniors unable to get their medications because of cost. Restricted and tiered formularies have put some medications out of financial reach for many, and a good number of my patients are choosing to forego the recommended—and most-appropriate treatment—rather than incur additional out-of-pocket expenses.

Very often my patients will ask me to prescribe a cheaper medication, even in cases where the patient and I both know they do better on the more-expensive product (whether it be a branded drug or more-expensive generic). And in situations where there is no cheaper alternative, they simply don’t fill the prescription. Sadly, many patients seem resigned to the fact that their health will suffer; but when faced with the choice of buying food or buying costly medication, they choose food.

My concern with the proposed Medicare Part D rule change is that it would further restrict seniors’ access to important antidepressants and antipsychotics—medications that have proven to be effective—and force more seniors into mental health crisis.

Not apples to apples

This is not to say that fiscal responsibility has no place in medical decision making. Who of us would oppose prescribing a drug that costs $4 a month in place of a drug that costs $1,000 a month if they both do the same thing? I advocate for responsible prescribing and know that many of the generic medications are good medications, and they work very well for many people.

But, and this is what makes psychiatric formularies so unique, not everyone responds equally to every medication. When it comes to mental health drugs, there are no apples to apples; every brain responds differently to medication, and while a less-expensive or generic may work well for some people, it may not work at all for others. Antidepressants and antipsychotics are not interchangeable the way blood pressure or cholesterol medications are, and when we find a drug that works well for someone, we must protect the patient’s access to it.

Coverage with no access

We protect patients’ access not just by making medication available, but by making it easily available. With fail-first policies, which require patients to work their way through a series of medications before receiving approval for a more-expensive drug, the process to obtain authorization can be cumbersome and time consuming. So much so that providers are discouraged from pursuing authorization and many patients choose to forego the request altogether.

For example, if I want to help a patient receive authorization for an antidepressant, I or one of my staff must submit paperwork detailing the patient’s failure with the formulary’s first-line antidepressants. Oftentimes, the request forms are returned to us asking for additional information, such as the exact dates of failure. It can take hours of staff time to track down the information, if we have it at all. A process this cumbersome risks putting convenience ahead of what’s best for the patient, and I fear we will see more of that if the Medicare Part D changes are approved.

Pennywise, but pound foolish

Having specialized in providing psychiatric care to older patients my entire career, I know that policies that unduly restrict access are pennywise, but pound foolish. For while there may be some immediate cost savings if we limit seniors to less-expensive antidepressants and antipsychotics, those savings are quickly negated if a patient becomes destabilized as a result of a medication change. I have seen patients who were stable for years deteriorate when switched to a new medication. Some end up requiring more physician visits as they adjust to new medication; some end up needing a day-treatment program; and some end up in crisis, requiring hospitalization. All of that costs our health system much more than simply providing the medication that works best for each patient.

Another cost factor to consider is that there is also a lot of co-morbidity in depression. When people are depressed, they have higher rates of heart disease and diabetes. When we limit seniors’ access to the full range of antidepressants, we risk an increase of depression among seniors, and when we do that, we are likely to see rising rates of other costly, chronic health conditions.

Why we must speak up

Many of my patients are people who grew up in a time when you work hard, you pay your bills, you don’t complain and you don’t look for handouts. These middle-class seniors, the great silent majority, are not calling their congressmen and they’re not raising Cain about losing access to the drugs they know and I know work best. They seem resigned, but I think we need not be. We must speak up and defend this vulnerable population, for restricting the Medicare Part D mental health formulary will have a profound and negative impact on millions of seniors and on our health system as a whole.

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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9 comments
afish
afish

I certainly agree with stephen's comments.  As a patient and professionally trained social worker, it is just as important to receive good cognitive therapy, along with some meds, but also include in one's treatment plan, alternative treatments for patients diagnosed with bipolar illness and depression.  diet, nutrition, exercise, getting outside in the sun and humor truly help us to stay in control.  Medications are only part of the tx plan and unfortunately, psych docs turn to psych drugs as the first step.  I'm not against psych meds as I have taken too many to name.  However, limiting these meds and incorporating alternative treatments can be a win-win when we have stabilized and I think there is a movement within the mental health community to begin addressing these alternatives in conjunction with cognitive behavioral treatment in order for patients to know what tools they can use when we feel we might be losing control of our illness.


The "pie" is finally beginning to expand and although there is no cure for bipolar illness, there are control mechanisms that we can incorporate in our healing process.

StephenBonin
StephenBonin

I have been a member of Depression and Bipolar Support Alliance, reading the BP and Esperanza magazines, as well as the outstanding brochures put out by DBSA, for 10 years.

While in my experience as a consumer I have had medications changed a few times, I believe what is documented: participation in cognitive behavioral therapy and support group are vital parts of the pie. In addition, the consumer is strongly instructed to get sunshine everyday, exercise, regulate sleep,  NOT lazily soak in unhealthy media but expose self to uplifting and edifying and informational and entertaining that is also decent media.

ln essence, I disagree with this doctor and ANYONE who espouses that the medication holds a starring role.

Wholistic health. Many slices of the pie. Time for healing. It's a family illness afterall, just like alcoholism. As one therapist told me, I am in the counseling office; however, other members of the family need help too.

Lobber
Lobber

Thank you for stating your case eloquently and accurately. Clearly you have your patients best interest at heart! Too bad many managed care companies and our govt do not!

ktcoll
ktcoll

Medicare recipients deserve to keep full access to quality mental health care. I will speak out about this any way possible - emailing my Congressman, contacting my senators, continuing the conversation to raise awareness - so this will not happen. It should be the decision of the provider and patient as to which medication works best. Cost should not be the over-riding factor.

afish
afish

another issue that must be addressed that I believe is important is that there is much fraud by various insurance companies and Medicare Advantge plans that CMS is not  addressing, thus leading to lack of accountability and over-sight by CMS.  If psych meds via Part D are to be continued to be covered, how will patients know that their Medicare Part D plan/provider is not committing fraud, thus costing taxpayers mucho dollars.  I believe that Medicare/Medicaid need a complete over-haul.  These 2 beaurecratic programs are out of control, have no real over-site systems in place and patients won;'t know there might be fraud unless their insurance provider for Part D really over-charges for meds and patients report this fraud to CMS.

afish
afish

additional comment to comments below - It is important wherein I believe there could be bi-partisan support for all members of congress to eliminate the penalty for Part D for Medicare patients along with eliminating the penalty for younger folks who don't initially sign up for the Federal ACA health insurance plan.  All penalties need to be taken out of health care reform.  Its too costly for seniors and younger folks

afish
afish

First and most important to Medicare Part D is do all Medicare patients, i.e., Seniors who initially enrolled in Medicare sign up for Part D?  I didn't and learned during open enrollment in 2013 that there is a penalty for all seniors who have Medicare who did not initially enroll in Part D.   That's 1% for every year I didn't enroll, along with finding another insurance plan, hopefully without a deductible to obtain Part D.  For patients who are receiving SSI (low income), these folks are automatically enrolled in Part D along with Medicaid patients.  I believe Part D of Medicare is a good program for patients who are taking a lot of expensive medications including various psych drugs.  To eliminate and/or reduce the various psych medications for seniors would be the same as eliminating chemotherapy for patients.  However, it is also important for seniors who do have Part D and are being seen by a psychiatrist who is prescribing various psych meds for depression/bipolar dx, that they must be tuned in to the other medications many seniors are taking.  The usual psych "cocktail" prescribed by various psychiatrists takes much time to "kick-in" and some don't work.  It is also important to remember that there are alternatives to the treatment of mental illness for seniors and others and this should be part of a patient's treatment plan.  Geriatric docs who are not trained and/or have little experience with the various psych meds available need to be trained if they are prescribing psych drugs for seniors.


It is no secret that many of the new psych meds are very expensive and for those seniors/patients who are benefitting from these psych meds, CMS should not eliminate these from their Part D plans.  After all, isn't this what Part D Medicare insurance is all about when it was initially instituted?  Whomever from CMS came up with this idea of eliminating and/or not covering certain psych meds for Seniors as an attempt to save money for Medicare, don't understand what the Part D of Medicare program is all about when it was implemented in 2006.  If CMS is going to go after psychiatric medications, then they need to look at all of the medications covered by Part D and not discriminate against seniors/patients who find their psych meds are helping them.  Regarding the issue of cost for these drugs and the "psych cocktail" involved, geriatric psych docs/patients/geriatric M.D.'s also need to encourage their patients to review their life style, focusing on diet, nutrition and exercise.  This is especially true for seniors dx with diabetes, high cholorestoral, high blood pressure and various heart disease dx.  It is nice to know that today there is a movement within the mental health community/providers that are looking at these alternative modes of treatment.  However, CMS should not single out various psych medications due to cost.  This is what I believe is a result of insurance companies/CMS/ACA specifically singling out the mental health population.  I believe the majority of seniors who are retired and receiving Medicare are not as "poor" as previous generations, depending upon which part of the U.S. A. where they live.  It is time for members of congress, no matter their political affiliation, to truly question CMS director in order to show the reasoning behind this change.  Remember, all of us on Medicare are paying for a supplement to Part A & B.  Federal retirees who retired under the old "PERS" system have a different if not better health care plan then those of us who are just regular retirees.



wheels259
wheels259

I am a 54 year-old disabled woman , and I  have had a hospital stay about 3 years ago,  shortened due to Medicare costs, and I was discharged with five bedsores, which required further treatment from home health care aides, and,  my mother who is 74, also has had her hospital stays shortened.  Now, she had to be re-admitted with lung problems just today!  I am FURIOUS!!