Although every state has now adopted some form of “step therapy” to control prescription drug costs, patient advocacy groups in Kansas remain deeply distrustful of the policy scheduled to take effect July 1.
Also known as “fail first,” the policy requires providers participating in KanCare, the state’s privatized Medicaid program, to start patients on less expensive drugs before moving them to more expensive alternatives if medically necessary.
“Taking prescribing out of the hands of doctors and putting it in the hands of administrators and people who are trying to make a profit is not good for patient care,” says Dr. Donna Sweet, a professor of internal medicine and a clinician at the University of Kansas School of Medicine-Wichita, where she focuses on treating patients with HIV and AIDS.
Advocates for Kansans with mental health disorders are particularly concerned even though legislators who pushed for the change say they needn’t be.
A ‘terrifying’ prospect
Rebecca Lyn Phillips, of Topeka, is one such advocate. She has schizophrenia and writes a blog about the challenges of living with the disorder. She says the prospect of step therapy is “terrifying” to many people with severe and persistent mental illnesses.
She wonders what will happen if a drug that a mental health provider is required to start a patient on fails.
“What does that mean?” Phillips asks. “Does that mean that a person with a mental illness does something that endangers someone else or themselves?”
Phillips’ concerns stem from experience. Several years ago, she stopped taking the initial medications she had been prescribed because she thought they robbed her of her personality. Phillips became paranoid and fled her home in a panic.
“I drove to Lyndon one night in the middle of the winter and slept behind a dumpster just thinking that people were going to harm me,” she says.
Eric Harkness, a Topeka pharmacist, has battled severe depression for most of his adult life. He’s unable to work because of his illness, but he’s an active member of the Kansas affiliate of the National Alliance for Mental Illness, a nonprofit advocacy group.
Harkness says he has needed to change medications several times over the years. A drug will work for a while — sometimes several years — but will suddenly become less effective, he says, recalling how frightened he was the first time it happened.
“I didn’t know what was going on at first, and my doctor didn’t either and my condition continued to deteriorate,” Harkness said. “I wound up losing my job, and my fiancé at the time wound up leaving because I was by no means any fun to be around.”
After an extended stay at the now-defunct Topeka State Hospital and a change in medications, Harkness improved. But he says the experience and others like it in the succeeding years demonstrate how important it is for him to be on the right medication. And that’s why he’s also concerned about the new step therapy policy.
“When you get someone outside the (treatment) room saying, ‘Hey, wait a minute. Let’s use this other medication instead of what you and your doctor picked out,’ my doctor and I both start to get kind of nervous,” he says.
A method of controlling costs
Dr. Susan Mosier, secretary of the Kansas Department of Health and Environment, says the concerns of patients and providers are overblown. The fact that most commercial health insurance providers and Medicaid programs in every state but Kansas already are using step therapy demonstrates that it’s an effective way to control prescription drug costs without compromising patient care, she says.
“Step therapy is an approach to prescriptions that is intended to control the risks that are posed by prescription drugs as well as their cost,” Mosier says.
Amy Campbell, director of the Kansas Mental Health Coalition, says the group is concerned about any policy that uses price to determine what medications providers are able to prescribe.
“Cost is not a good determining factor for what is the best prescription medication for people with mental illness,” she says. “These policies have been known to interrupt treatment.”
Sen. Jim Denning, an Overland Park Republican and vice chair of the Senate Health and Human Services Committee, helped win passage of the bill authorizing the step therapy policy.
“With pharmacy consuming more and more of the Medicaid dollar, I think it’s just time that we start taking a look at it,” Denning says, noting that prescription drug costs for KanCare, the state’s privatized Medicaid program, are “growing at 10 times the rate of inflation.”
Step therapy will save KanCare an estimated $10.6 million annually, according to KDHE. Gov. Sam Brownback is banking on the savings to help balance the fiscal year 2017 budget.
Rep. Dan Hawkins, a Wichita Republican and chair of the House Health and Human Services Committee, also supports step therapy. But at the end of the session when a final version of the bill was being negotiated, he insisted on including more patient protections. Among other things, they allow a doctor to bypass an inexpensive drug for a more expensive one if he or she believes the less costly medication would be ineffective or harmful.
Kari Rinker, senior advocacy manager of the Mid America Chapter of the National Multiple Sclerosis Society, says that and other protections, including one that requires provider appeals to be handled within 72 hours, helped alleviate some of the concerns of patient advocates. Still, she says, advocates want to work with KDHE to add more protections in the rules and regulations that will spell out how the policy will work.
“Our job is not done,” Rinker says. “The devil is in the details, and we need to continue to advocate for some more specific protections in the process.”
For instance, Rinker says, advocates want to see an enforcement mechanism added to the bill to ensure that the managed care companies that oversee the day-to-day operations of KanCare adhere to the 72-hour allowance for appeals.
No mental health exception
Mental health advocates wanted more than that, asking lawmakers to maintain a provision in state law that prohibited step therapy for behavioral health drugs. That didn’t happen, as the bill that passed repealed that provision.
Hawkins says lawmakers concluded it would have been unfair to carve out one class of drugs.
“That just wasn’t something we could do. Because once you carve out one, you have to start carving out everybody, and that just wasn’t going to work,” he says, stressing that other provisions in the bill should ease the concerns of mental health advocates.
The bill requires KDHE to first get approval from the Mental Health Medication Advisory Committee and the Drug Utilization Review Board before it implements step therapy for mental health drugs.
Campbell of the mental health coalition says while those protections are important, they aren’t enough to alleviate advocates’ fears.
“No ifs, ands or buts, the legislation does allow step therapy policies to be implemented for mental health medications, and that is our concern,” she says.
Jim McLean is executive editor of KHI News Service in Topeka, a partner in the Heartland Health Monitor team.
