A legislative committee’s recommendation could reignite a debate over whether the state should have the power to regulate Medicaid reimbursements for mental health medications, as it does for other types of drugs.
Kansas law currently bars state officials from using regulatory tools — such as prior authorization and preferred drug lists — to manage the use and cost of mental health medication prescribed to Medicaid recipients. The Legislature’s KanCare Oversight Committee recommended repealing that law last week, saying the state needs to prevent inappropriate use of such drugs. But mental health advocates say there are other ways to do that, and they oppose any repeal of the law.
“The issue is not new to me,” says Kyle Kessler, executive director of the Association of Community Mental Health Centers of Kansas. “You want to be really cautious how you proceed with policy changes for this population and people who suffer from mental illness.”
In suggesting the change to state law, Rep. David Crum, a Republican from Augusta, says he aimed to protect Kansans with persistent mental illness while attempting to prevent the inappropriate but common use of antipsychotic drugs for other types of patients.
“Patients with persistent, chronic mental illness should be able to receive antipsychotic drugs with no requirement for prior authorization,” Crum says. “However, for all other patients, Kansas Medicaid needs to be able to perform safety edits to assess whether drugs are being prescribed appropriately.”
What sort of change that would represent from current law is unclear, though, because the statute now on the books does not describe the threshold for “persistent, chronic mental illness.”
“That may be something we’re going to have to define if we’re going to put this into law,” says Sen. Laura Kelly, a Topeka Democrat. “I don’t have a problem with looking at that delineation, but I do think that’s going to be difficult to determine.”
Crum, who did not seek re-election and is serving his final weeks in office, says persistent, chronic mental illness could be defined in legislative hearings on the issue next session. He says he was especially concerned about antipsychotic drugs being inappropriately prescribed to control elderly patients and residents of nursing homes suffering from dementia.
Mitzi McFatrich, executive director of Kansas Advocates for Better Care, says she had warned the oversight committee about that practice’s prevalence in Kansas at previous meetings. However, she never suggested the solution was to repeal the ban on Medicaid regulation of mental health drugs.
“In my mind there’s no clear intersection on those issues,” McFatrich says.
Instead, McFatrich says her suggestions include increasing staff levels at facilities for the elderly and making sure staff members are trained “so they can meet a resident’s needs for attention and redirection in ways that don’t just involve medicating them.”
Elderly patients with dementia are generally covered by Medicare but some also receive Medicaid to help with costs not covered by the primary insurance.
Previous focus on children
Previous attempts to regulate prescription of antipsychotic drugs have focused on a different demographic: children.
The Kansas Health Policy Authority, a semi-autonomous state agency disbanded in 2011, cited several statistics about children’s health in a 2009 report that bolstered its recommendation that the Legislature allow more regulation of mental health drugs.
About 17 percent of children on Medicaid were receiving antipsychotics like Risperdal or Abilify, the report said, while the National Institutes of Mental Health estimated that only about 1 percent of children had conditions like bipolar or schizophrenia that those medications are intended to treat.
The report noted that the incidence of those mental illnesses would likely be higher among the Medicaid population than in the population at large because mental illness can be a qualifier for Medicaid coverage.
“However, the greater percentage of children receiving atypical antipsychotics cannot be explained by this population characteristic alone,” the report said.
The health policy authority report said that a significant number of children were being prescribed the antipsychotics off-label — for use other than what the FDA had studied — and suggested that deserved more scrutiny.
The report also said that in a three-month period in 2008, 214 Kansas children on Medicaid were prescribed five or more psychotropic medications, which are used to treat psychiatric conditions, and 201 were prescribed two antipsychotic medications at the same time.
“Scientific evidence supporting the use of multiple psychotropic medications simultaneously is lacking,” the report stated. “Reasons for these potentially inappropriate prescribing patterns have not been isolated.”
The report cited a possible link to spotty access to psychiatric care in some areas of the state, noting that 63 percent of mental health drugs in Kansas were prescribed by general practice physicians and other medical professionals not trained in psychiatry.
The Legislature declined to take up the health policy authority’s recommendation to create a preferred drug list for Medicaid, which mental health advocates opposed.
An issue of cost?
Amy Campbell, a lobbyist for the Kansas Mental Health Coalition, says the authority’s report did not provide any solid evidence of prescription misuse.
A child could be prescribed multiple medications during a three-month period, she says, without actually taking those medications simultaneously. For instance, a child could be prescribed a second medication if the first one was ineffective, or could be prescribed one by a general practitioner and then another in a hospital after a mental health crisis.
“The issue there that never was resolved was, were any of these doctors contacted?” Campbell says. “Were any of these drugs actually being prescribed in an unsafe manner, or were these situations where children picked up these drugs in a hospital setting?”
Eric Atwood is director of medical services at Family Services and Guidance Center, a community mental health center in Topeka that serves children of northeast Kansas.
Atwood says research does not suggest Kansas is an outlier in its psychotropic prescription patterns. He says prescription costs, more than safety concerns, motivate state officials to more tightly regulate the use of mental health drugs.
“The studies that have really looked at that have not shown there are dangerous issues of prescribing in Kansas as compared to other states,” Atwood says. “The basic issue is cost and cost containment.”
The health policy report from 2009 did highlight mental health medications as a major cost driver in Medicaid, citing their expense as 40 percent of the overall growth in the program’s prescription drug spending the previous year. The report recommended using tools like prior authorization and a preferred drug list to limit spending.
A preferred drug list allows states to negotiate rebates from pharmaceutical companies, which then have their medication designated as the drug of choice to treat a specific ailment. Prior authorization requires a physician who prescribes a different drug to provide an explanation that is then reviewed by a panel of experts before the prescription is filled.
The state uses both tools for other prescriptions within Medicaid, but mental health advocates have successfully argued that drugs that treat mental illness should be exempt from them.
Mental illnesses are not uniform, they argue, and sometimes patients must try several drugs before they find one that successfully treats their symptoms. Delaying a prescription for someone with a mental illness by requiring prior authorization, Kessler says, can cause a far more costly trip to an institution, or even prison, if the patient involved has a crisis.
“More and more of the literature is saying prior authorization and (preferred drug lists) on psychotropic medications isn’t good policy,” Kessler says. “You’ll just see cost-shifting to other areas.”
Digital records and communication have the potential to speed the prior authorization procedure, and temporary drug supplies can be made available in the interim.
But Atwood says the system isn’t there yet. He says prior authorization requirements in their current form delay treatment and create “meaningless hurdles and administrative obstacles” for providers.
Campbell says a better alternative would be to renew an abandoned process of post-prescription review in which a panel of experts identified unusual prescribing patterns, contacted the physicians involved and offered consultations.
Campbell says her organization wants to work with the Legislature to determine if any misuse of mental health drugs is happening. If issues are identified, she says, they then can be addressed through education rather than repealing the statute that bars Medicaid management of such drugs.
“We believe there is room for the examination and implementation of policy to help with the safe prescribing of mental health medications,” Campbell says. “But simply wiping out the statute would result in a serious loss of protection for mental health clients.”