Psychiatric drug policy shift stemmed from governor’s report

A policy that could remove existing protections for psychiatric medications purchased through Medicaid became part of the state’s proposed government reorganization effort after it appeared in a consultant’s recommendations to Gov. Chet Culver.

As The Iowa Independent first reported Wednesday, such medications are typically not placed on preferred drug lists. Under current state law, physicians who prescribe the medications for Medicaid patients are free to select the drugs believed to best serve the individual patient. They are also free to switch patients to a different medication if the initial drug was not tolerated well or failed to reduce symptoms.

New language in the reorganization bill, which has been approved by the state government and appropriations committees in the Iowa Senate, removes the exception for psychiatric medications and calls for only the drugs by pharmaceutical companies that have entered into an agreement with the state to be placed on the preferred list.

State officials estimate that the change would save the state $400,000 the first year and $1.3 million over five years.

State Sen. Randy Feenstra, a Hull Republican who serves as the ranking member on the State Government Committee, said he questioned how the language, which has previously been rejected by the Iowa legislature, found its way into the bill. According to mental health advocacy groups, the issue was explored two years ago and, after presenting their case to the legislature, the policy change was dismissed.

“When I asked the question to the majority [party], they stated that the governor’s consultant came up with it and that the governor demands it stays in,” said Feenstra, who has requested the language be removed from the bill.

He described medical treatment of those who have mental illness as “complex.”

“Mental health patients can have the best quality of life by taking specific medications prescribed through their physician,” Feenstra said. “Finding the right set of prescriptions takes time as different mixes might not yield the best results. It has been noted that although one drug should do the same as another, each person reacts differently to each drug. After noting this, I fully believe we should not change peoples’ medications.”

His assessment of the situation is very similar to that of numerous mental health advocates, who also point out that individuals with a mental illness who are unable to obtain prescriptions both tolerated by the body and effective for their symptoms are much more likely to become a larger taxpayer burden due to homelessness, emergency room visits, incarceration or committed medical care.

The language that appeared in the report issued through the governor’s office was brought to the table by the Iowa Department of Human Services. The agency’s spokesman, Roger Munns, readily admits that the change is something that has been viewed favorably by the department for some time.

“We have been advocating the addition of more psychotropic drugs to the preferred drug list for several years, and for good reason,” he said. “The purpose is to save public money without undermining the availability of mental health medications for people receiving Medicaid.”

The agency’s proposal, according to Munns, contains a “grandfathering” clause to exempt current prescription holders, and will only apply to new prescriptions. He also noted that drugs not on the preferred list could still be purchased through Medicaid, provided prior authorization is obtained.

“The process is not cumbersome,” Munns said. “The turnaround time for prior authorization is about two hours.”

Margaret Stout, executive director of the Iowa chapter of National Alliance on Mental Illness (NAMI), isn’t convinced that existing time frames for prior authorization are sustainable.

“That might be the case right now — and I have no reason to believe that it is not,” Stout said. “But what happens when instead of a select few psychiatric drugs, many more are added to the list? And, even if the initial request for prior authorization is answered in two hours, what happens if the request is denied? At that point the prescribing physician — whether a psychiatrist or a family doctor — will need to spend additional time on the appeal process.”

Stout also notes that although the Department of Human Services has indicated that its proposal included language that would “grandfather” existing prescription holders, such language does not appear to be in the bill before legislature, and would not directly or clearly address medication adjustments that are often necessary during the treatment of those with mental illness.

States that use preferred drug lists evaluate pharmaceuticals deemed “equivalent,” and most often select the least costly medications for “preferred” status. For example, a state would likely prefer a generic of a name brand solely on the basis of cost. Medications that can be taken less often are also typically more expensive than the same medication in the original more frequent dosage. So, in that type of situation, which was recently faced by Florida authorities, the state often selects the least expensive option for inclusion on its preferred list.

Mental health advocates, however, are quick to point out that “equivalent” does not mean “same,” and that even inactive ingredients in medications, which often differ from name brand to generic, can digest at different speeds and result in the body absorbing active ingredients more quickly or slowly.

The language that appeared in the report released by the governor’s office:

CHANGE THE WAY MEDICAID PAYS FOR UNIQUE MENTAL HEALTH MEDICATIONS
The Iowa Department of Human Services currently places all chemically unique mental health prescription drugs on its preferred drug list (PDL)
for Medicaid recipients. Some of these medications are very costly and states have used contracting mechanisms to obtain rebates on high‐cost medications from manufacturers. Iowa DHS proposes to require the makers of these medications, who wish to sell drugs to the Iowa Medicaid program, to enter into a contract for supplemental drug rebates to the State. If a drug manufacturer does not enter into a contract, DHS could place the mental health medication on the nonpreferred list of drugs, thus requiring physicians to obtain prior authorization before the Medicaid recipient can obtain the drug.

The language that currently appears in SF 2088:

DIVISION XXVII
MEDICAID PRESCRIPTION DRUGS

Sec. 389. Section 249A.20A, subsection 4, Code 2009, is amended to read as follows:

4. With the exception of drugs prescribed for the treatment of human immunodeficiency virus or acquire immune deficiency syndrome, transplantation, or cancer with the exception of drugs and drug compounds that do not have a significant variation in a therapeutic provide or side effect profile within a therapeutic class, prescribing and dispensing of prescription drugs not included on the preferred drug list shall be subject to prior authorization.

Sec. 390. MEDICAID NONPREFERRED DRUG LIST PRESCRIBING. The department shall adopt rules pursuant to chapter 17A to restrict physicians and other prescribers to prescribing not more than a 72-hour or three-day supply of a prescription drug not included on the medical assistance preferred drug list while seeking approval to continue prescribing the medication.

Sec. 391. MEDICAID MENTAL HEALTH MEDICATIONS. The department shall adopt rules pursuant to chapter 17A to require that unless the manufacturer of a chemically unique mental health prescription drug enters into a contract to provide the state with a supplemental rebate, the drug shall be placed on the nonpreferred drug list and subject to prior authorization before a medical assistance program recipient is able to obtain the drug.