The future of successful treatment for Utah’s mentally ill is at severe risk should House Bill 18 pass through the 2016 Utah legislative session. This bill seeks to revoke the Medicaid Preferred Drug List (PDL) exemption for psychotropic drug classes, including antipsychotic, psychotropic, antidepressant, anti-conversant/mood stabilizers, anti-anxiety, attention deficit hyperactivity disorder stimulants and sedative/hypnotic drugs.
The PDL authorizes Utah Medicaid to require a prior authorization for non-preferred drugs, however, psychotropic drugs remained exempt because, for those battling mental illness, missed doses, delays in receiving medications, discontinuation or changes in doses or specific medication can result in devastating relapses.
The bottom line is this bill will tie the hands of psychiatric prescribers significantly, as they are the ones to best understand the nuances of psychotropic medications, which are all a bit different from one another. Each medication has a particular profile of side effects, strengths and weaknesses: One antipsychotic med will help patients calm down, one will give them more energy; one will help them sleep, one will aid alertness; one will help restore their appetite and another will reduce their appetite; one is safe in pregnancy, one is safe for patients taking methadone; one is fast-acting, others are available as an injection; one worked for their brother, one is too similar to a med that caused side effects in the past.
The duty of the prescriber is to collect as much relevant information as possible, and then try to pair a patient up with the medication most likely to work for them the first time. Prescribers do not have a crystal ball and do not always succeed on the first attempt, but all training and experience is put to use in the effort of attempting to find the right medication(s) for each patient as quickly as possible, thereby reducing the financial and human cost of untreated mental illness.
HB18 is not troubling because it limits access to new medications, rather, because it limits access to a number of options. Period. If a prescriber can only choose from the generic meds, half of the time he or she will be forced to choose a med that would otherwise not have been the first choice for a given patient. This increases the likelihood of clinical failure.
Further, a process of submitting requests for exceptions or prior authorizations is not feasible. Medicaid patients often do not have working cellphones, reliable transportation, and personal organizers. Getting back to someone days later about whether or not authorization has been received for their best medication choice is likely to result in a high number of communication failures, missed opportunities and clinical failures.
Mental illness is not a field in which choices of medication should be intentionally limited, nor should trained and experienced providers be prevented from prescribing their first choice of psychotropic medication for their patients. This “fail first” method will place our poorest and most vulnerable populations at increased risk of emergency room visits, hospitalizations, lost jobs, homelessness and even incarceration.
There is no amount of projected savings to Medicaid that can — or should — be bartered for the value of these human lives.
Samuel Vincent, APRN, is a nurse practitioner at the Fourth Street Clinic, clinical instructor at University of Utah’s College of Nursing, director, Behavioral Health Services for Wasatch Homeless Healthcare, co-chairman of Utah Behavioral Health Community Network, and has served on the executive committee of Utah Behavioral Health Planning and Advisory Council.