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Testimony: Do Not Restrict Access to Psychiatric Medications

Michael B. Friedman, our public policy consultant, gave this testimony at a public hearing held by the Mental Health Committee of the New York State Assembly on January 15, 2003.

My name is Michael Friedman, and I am the Public Policy Consultant for The Mental Health Association of New York City and The Mental Health Association of Westchester County. These MHA's provide direct service, community education and advocacy to ten's of thousands of people each year. We appreciate the opportunity to testify today regarding access to psychiatric medications.

Committee Established to Reduce/Contain Medicaid Costs

As you know, last year New York State established a Pharmaceutical and Therapeutics (P & T) Committee for Medicaid. The goal of the committee is to reduce, or at least contain, Medicaid costs. Given the fiscal problems confronting New York State and its local governments, it is important to find ways to reduce spending so long as it can be done without depriving people of the services that are critical to their well being.

Must be Done Without Depriving People of Drugs They Need

The question then is whether the P& T Committee can reduce Medicaid spending without depriving people of access to the medications they need. The answer is complex because the P & T Committee has two fundamental functions. One is to establish a program through which people on Medicaid will get generic drugs instead of brand-name drugs. The other is to give preference to the use of certain specific medications from a particular family of drugs while restricting access to others even though the preferred medications are not clinically equivalent to the restricted medications.

Not All Generic Drugs are Clinically Equivalent to Brand Names

In general we believe that it is reasonable to require the use of "clinically equivalent" generic medications. However, it is important to emphasize that not all drugs that are called "generics" are clinically equivalent to the brand-name drugs for which they are substituted. The New York State P & T Committee has recognized this and appears to be making provisions not to require the use of generics that are not clinically equivalent. It has also been developing a procedure through which exceptions can be made regarding even clinically equivalent generic medications. So far so good.

However, the next step of the P & T Committee will be to restrict access to certain brand name and generic medications, even if the person's physician prescribes them. We believe that this could have disastrous consequences for people with psychiatric illnesses even if a procedure is created to appeal the Committee's rules and to get exceptions made.

Appeals Processes Problematic

Appeals processes have two notable problems. First, they are often difficult, arbitrary, and time-consuming-designed in fact to discourage appeals even when they are medically appropriate. People on Medicaid should be able to get the medications their physicians believe are most appropriate without running a bureaucratic obstacle course.

Second, processes to get approval for a medication not on the preferred list are frequently built on the premise that access should only be given if the preferred drug has been tried and failed. It makes no sense to require a physician to prescribe a medication he or she believes will be ineffective just because it is on the state's preferred list. A physician's judgment about what is likely to be the most effective drug should be questioned only if there is good reason to believe that the physician is making an error in medical judgment. In such a case it should be up to the state to appeal to the physician to use a more appropriate drug rather than to force a physician to appeal an arbitrary list.

Sound Clinical Reasons for a Physician to Choose One Drug Over Another

It is critical to be clear that there are sound clinical reasons for a physician to choose one drug rather than another, even if they are drugs from the same family.

History of response to medications is one such reason. If a patient has tried and not responded well to a medication that is on the state's preferred list, the state should not require him or her to try the drug again when they become eligible for Medicaid or when the restrictive drug formulary is put in place.
Changing from a medication that is working to one which has not yet been tried can be very risky for people with severe psychiatric illnesses. Changing medications can precipitate psychotic breaks, with all the terrible suffering they entail.

Should such a risk be taken simply in order to try a medication on the state's preferred list? We think not.

Choice of Medications Based on Variety of Factors

Besides history, physicians' recommendations about medications are based on a variety of considerations which are too subtle to be captured in a list prepared by a Committee charged with holding down state spending.

Often there are combinations of symptoms to be taken into account. A person who is depressed is different from a person who is depressed and anxious or who is depressed and obsessive compulsive and so on.
Different medications often have different side effects. For example, many anti- psychotic and anti-depressant medications contribute to weight gain, to loss of sexual ability or interest, to a feeling of lifelessness and so on. It is very important to try to prescribe medications that have the fewest side effects.

Side Effects from Medication Can Create Other Medical Problems

One reason to avoid side effects, especially weight gain, is the medical problems they contribute to. It is not unusual for people to gain 50 to even 100 pounds in a few years after beginning anti-psychotic medications. This contributes to greater risks of diabetes, high blood pressure, stroke, heart attack, etc. It is important both to the well being of the patient and to the long-term medical costs of the state to prescribe medications with an eye to avoiding medical complications.

It is also important to prescribe medications that patients will agree to take. Lack of willingness to take psychiatric medications (usually referred to as lack of "compliance") is the source of a great many relapses as well as periods of very low quality of life for people with severe and recurrent mental illnesses. Patients often reject medication because of its side effects. What would you do if you were told to take a medication that would make you fat and impotent and which would also make you feel dead inside? You would at least demand that your doctor try to find something else to manage your condition. Physicians must have the freedom to prescribe medications that the patients will agree to take.

State's List of "Preferred" Drugs Cannot Keep Up With Drug Development

Finally, it is important to keep in mind that very rapid progress is now being made regarding psychiatric medications. New drugs, generally with fewer side effects, are introduced frequently. In theory the state's preferred list could be updated every time a new drug is introduced. But given the nature of bureaucracy and the goal to save money by negotiating quantity discounts, how likely is it that the new drugs will get on the preferred list rapidly?

Those of us who have been advocates for high quality care for people with serious mental illnesses remember all too well the battle we had to wage in New York State a few years ago to get chlozapine approved for Medicaid payment. It was a drug that contributed to the recovery of a large percentage of people who did not respond to other anti-psychotic medications, but it was expensive and the state was more concerned about the cost than about the lost lives of thousands of people. We won that battle, so we know that the state can, with pressure, do what is right despite cost. But we also know that without extensive advocacy the state will put the need to hold down costs ahead of the needs of people with serious mental illnesses.

Do What is Right Despite the Cost

We urge you:

To limit the function of the P & T Committee to managing the state's reasonable requirement to use clinically equivalent generic drugs
To strip the committee of the mandate to restrict access to medications that can be critical to the recovery of people with serious mental illnesses

Thank you again for the opportunity to speak today.

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