Savings don’t justify changing state’s psychiatric drug policy, advocates say

Saddled with potential budget shortfalls in excess of $450 million, Iowa lawmakers are understandably on the lookout for ways to slash state spending. But some health care advocates are warning that proposed changes to prescription medication policies are shortsighted and will do far more long-term harm than good.

Creative Commons photo by jimmywayne via Flick

If Senate File 2028, the government reorganization bill, is passed as written, only state-approved psychiatric medications will be readily available to individuals on Medicaid. Medications that do not appear on the approved list will only be paid for if a physician requests and receives a waiver on behalf of the patient.

Although Iowa has utilized a preferred drug list for some time, the state has also granted exceptions for specific conditions that tend to require the most complex — and often most expensive — medications. Iowans on Medicaid who have mental illness, Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS) or cancer, as well as those who have undergone a transplant, have been granted exceptions under the preferred drug list, and their physicians have been free to prescribe whatever medication has worked best without needing to obtain prior state authorization.

Language in the government reorganization bill removes all such protections for “drugs prescribed for mental illness” and, advocates argue, is setting the stage for small immediate savings, much larger long-term expenditures and the potential of massive human suffering.

“Mental illness is a very complex and individualized,” said Carol Porch, an Iowa City mental health advocate. “What works for one person may not work for another, or may cause side effects in one person and be perfectly fine for another. There are even differences between brand name drugs and generics that have the same active ingredients because the non-active parts, or fillers, can create a situation where the drug can be more quickly or more slowly absorbed by the system. When dealing with psychiatric medications, all of this is a factor that determines the overall health of the person and their place in society.”

Even for the most mild mental illness, finding the most helpful and well-tolerated medication and dose can be difficult — often requiring multiple trials because effectiveness and reactions can vary from individual to individual. At least as early as 2004 the American Psychiatric Association’s Office of Healthcare System’s and Financing warned against limiting access to psychiatric medications because even those that have similar overall effectiveness also have specific mechanisms that can affect each person differently.

Upon completion of a study specific to schizophrenia, the National Institute of Mental Health concluded that “families and physicians need more, not fewer, choices” of prescriptions because, in part, “to say the medications are equivalent is not to say they are identical.”

Margaret Stout, executive director of the Iowa chapter of National Alliance on Mental Illness (NAMI), understands that the budget is tight, and that legislators need to make cuts that will save money.

“Over time, this policy will end up costing the state much more money than it would have paid for psychiatric prescriptions,” Stout said. “Our national organization has already given Iowa a D when it graded the states’ systems for serious mental illness. I know — and I’ll even predict — that if this is passed that our state will see increased homelessness and more people entering the criminal corrections system.”

The situation in Iowa, where the state is considering closing its only dual-diagnosis care center and there have been waiting lists for last-resort, state-funded care, is especially dire, she said. Even if the state fulfills its aim of closing the Mount Pleasant facility and maintaining the existing number of available beds, the previous need already out-weighed the existing services.

“We are headed in the wrong direction when it comes to caring for those with mental illness,” Stout said.

The overall economic climate in Iowa and subsequent across-the-board cuts mandated by Gov. Chet Culver has also resulted in Medicaid providers being paid less by the Iowa Department of Human Services. Under the proposed preferred drug list change, physicians who believe their patient will benefit from a medication not on the list would have to appeal to the state for authorization to try to the drug. Advocates wonder how many physicians, already underpaid by Medicaid, would be willing to go that extra distance for low-income patients.

“I really worry that we are setting ourselves up for two different standards of care,” Stout said. “One for those who have, and another for those who don’t.”

Porch is also focused on those who utilize the Medicaid program and may not be in a position to offer their own voice and experiences to legislators.

“What really is at stake here is that this change in policy has the potential of creating a lot of human suffering. That is just not acceptable,” Porch said.

Senate File 2088 has been passed by the Committee on State Government and is currently before the Senate Appropriations Committee for further review.