Getting worse before better

Imagine the state of Maine decided to reduce highway repair costs by allowing highways to deteriorate further than usual before repaving. Among the unintended consequences would be more expensive repairs on insufficiently maintained highways and reduced tourism.

This would be dumb policy costing Maine taxpayers and businesses dearly in the attempt to save money.

Something similar will take effect July 1st. The Department of Human Services (DHS) is about to adopt rules for the prescribing of medications by physicians in an effort to reduce costs to the state’s MaineCare prescription program – rules which will ultimately cost far more than they save.

To understand this complex situation, a bit of background is necessary.

Primary care providers often refer severely mentally ill individuals to psychiatric specialists who are trained and experienced to help these folks with their painful and difficult illnesses.

The farther north of Portland one goes, the greater the shortage of specialists prepared to treat these patients, the great majority of whom rely on MaineCare, the state’s Medicaid based insurance plan.

These patients have longstanding, complicated combinations of disorders that cannot be cured, but can be significantly improved by finding combinations of modern medicines in conjunction with supportive care (e.g. case management, psychotherapy). If these patients can be encouraged to stay on their medications, they can make use of other treatments, function in the community, and stay out of expensive psychiatric hospitals.

Now add to this mix the fact that modern psychotropics (a fancy word for medications targeted to alter the brain and mind in constructive ways with the least possible side effects) are priced extremely high in America. American prices are much higher than in almost every other nation.

To achieve cost reduction, DHS hired consultants.

They advised establishing rules to require caregivers to prescribe medicines from a particular category according to a predetermined sequence – first the medicine higher on the list must fail to help the patient before the next medicine on the list can be tried. Where the drug is on the list depends on the cost of that medication to the state. If a drug is very expensive, then not only must medicines higher on the list fail to help, but the prescriber must fill out a justification, fax it to Augusta and wait for someone to let them know if the justification is adequate. This is an expensive and time-consuming process.

Is the idea to coerce pharmaceutical companies to give large rebates to the state in order to get their drug higher on the list relative to its competition?

Indeed, a few companies have responded and given deep discounts to DHS. So, what’s the problem?

The problem is that most folks with severe and chronic mental disorders find it difficult to accept that taking their medications on a consistent basis is crucial to improving and maintaining their improvement. Their medications help them to function in the community, to work or volunteer, and to stay out of emergency rooms, hospitals and jails.

The major reason patients stop taking their medications is side effects. Psychiatric specialists partner with their patients to determine what side effects are most troubling for a particular person and use the prescriber’s knowledge and experience to pick the medications least likely to provoke that patient to discontinue.

Thus, the antipsychotic medication with the lowest cost to DHS and therefore the one we must give out first under the proposed rules happens to be one with the greatest likelihood of producing abnormal movements (potentially irreversible), often leading to significant weight gain (complicating medical disorders like heart disease and diabetes), and has been recently associated with breast cancer in women and strokes in the very old.

Even if a patient has had some of these side effects from other medications in the past and is highly likely to discontinue any such drug and then perhaps refuse to try another – still that’s the first drug we must use in its category!

So, in order to save 3 to 5 percent of total psychiatric drug costs, psychiatric specialists, who feel considerably challenged to help severely and chronically ill patients as it is, will now be forced to put aside our expertise. We will be required to prescribe according to a sequence determined largely or entirely on cost.

We will no longer be able to base our clinical decisions on careful understanding of a patient and medications. The new policy is not well-reasoned. Individualized specialty care is eliminated; it is care by bureaucratic fiat.

The costs in prolonged human misery and even lives will be tragic. But the irony is that studies by HMOs have demonstrated that using restricted formularies costs far more in physician office and emergency room visits, along with greatly increased hospitalizations at $600 to $1,200 dollars per patient day! And our psychiatric hospitals in Maine are already full on most days.

The time it will take to fill out the paperwork necessary to request a medication change for a drug requiring “Prior Authorization” will aggravate the already severe psychiatric specialist shortage in rural middle, downeast and northern Maine.

More psychiatrically ill patients will not have the benefit of seeing providers with the specific training and experience necessary to treat them.

I don’t think of any of my patients as “crazy” or “insane.” Most of our patients are courageously doing the best they can, given their situations. But this new prescribing policy, now that’s insanity.

Tom Rusk, M.D., is chief of adult psychiatry at Community Health and Counseling Services in Bangor.