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Indiana Medicaid mental health list worries advocates

March 14, 2011

A plan to cut Indiana Medicaid costs by limiting access to certain antidepressants, medicine for attention deficit disorder and other mental health drugs has advocates worried that some patients could be denied the treatment they need and end up in hospitals or even behind bars.

The state budget bill moving through the Indiana General Assembly would save about $7 million each year by creating a list of preferred mental health drugs and trying to win larger rebates from manufacturers. Groups representing doctors as well as patients and their families say it could endanger people with ADD, depression, schizophrenia and other mental illnesses.

"The money they're going to save, if you increase emergency room visits or you increase involvement in the criminal justice system, that money evaporates pretty quickly," said Mike Kempf of the National Alliance on Mental Illness-Indiana, who has a son with schizophrenia.

State Medicaid chief Pat Casanova pledged that health care experts — not bureaucrats — would be making the decisions about what medicines to approve, and that the determinations would come quickly. Indiana already has preferred drug lists for other diseases, she said, and her office found the state among only nine that do not manage mental health drugs.

A panel of pharmacists, health care professionals and academics review drugs when they enter the market and make recommendations to a second panel of experts that decides which of them go on the preferred drug list, Casanova said.

"It's not a clerk in an office or anything like that making a decision. It's a very thoughtful process," she told the Associated Press.

Medicaid enrolls more than 1 million Indiana residents in programs such as Hoosier Healthwise for children and pregnant woman, the Healthy Indiana Plan for uninsured, low-income adults and Care Select for people with disabilities. The state did not respond to a request for information about how many receive mental health medicines.

Under the bill, doctors prescribing drugs not on the list must seek prior authorizations that would be reviewed within 24 hours by Indiana Medicaid's pharmacy benefits manager, Casanova said. If the patient already takes a non-preferred drug, the doctor can provide a three-day supply while the authorization is pending. Psychiatrists would not need prior authorizations.

"We have no intent to cut people off drugs," Casanova said.

But that's exactly what some advocates fear. Stephen McCaffrey, president of Mental Health America of Indiana, noted that 60 of Indiana's 92 counties have no resident psychiatrists who would be able to prescribe drugs that are not on the preferred list. He also noted that Gov. Mitch Daniels' administration has tried to downsize state psychiatric hospitals and endorsed a report showing Indiana could save more than $1 billion over several years by moves such as steering lower-level felons into probation, community corrections and drug treatment.

"One of the tools in the toolbox to make those successful is to make sure there's appropriate access to medications in Medicaid," said McCaffrey, whose group includes doctors and consumers.

Indiana prison officials have said in recent years that nearly 20 percent of state inmates have been diagnosed with a mental illness and 12 percent take mental health drugs.

Ann MacLaren of Fishers, who has worked as a pharmacist in hospitals, retail, research and other areas, told the Indiana House Ways and Means Committee earlier this year there's no "one drug that fits all."

"Everyone is different and how we metabolize drugs is different," MacLaren said.

Beth Karnes, president of the Indiana Mental Health Memorial Foundation affiliated with McCaffrey's group, said that when bureaucrats interfere with seriously mentally ill patients receiving the medications that work best in them, it costs Medicaid more because of crisis care, emergency room visits and hospital admissions.

A 2008 study in Ohio estimating the cost of prior authorizations for certain mental health drugs found they would save $6 million but cause more than $18 million in adverse health consequences, Karnes said.

House Ways and Means Chairman Jeff Espich defended the preferred drug list proposal, saying Medicaid is the only part of Indiana's budget that's growing and is projected to reach $2 billion during the 2013 state fiscal year.

"We're at the point where we're looking to save pennies just because times are so tough for Hoosier families and the taxes they pay," said Espich, R-Uniondale.

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