The Access to Medications Task Force met on December 9, 2002 to review the trends, practices and alternatives in pharmaceutical cost containment; and discuss and develop recommendations and strategy.
The Task Force developed guidelines to organize its work. The policies and advocacy strategies that flow from these guidelines were based on extensive discussions and address both short and long term issues, as well as the needs and interests of NAMI’s members at federal, state and local levels.
The Task Force recommends that NAMI pursue the following strategies to ensure open access to medications in the current budget deficit environment. They should be seen as an integrated, comprehensive approach to addressing the needs and interests of the people we serve.
1. Support an Increase in Federal Medicaid Assistance Percentage (FMAP)
The federal government reimburses states for a substantial portion of their Medicaid costs. The Medicaid budget problems that states are experiencing are being exacerbated by reductions in federal Medicaid matching payments to some states. These payments are based on the FMAP, which is determined by historical economic data.
The current FMAP rates are based on data from years prior to the recession, placing a number of states in the position of having to fund their Medicaid programs with fewer federal dollars at a time when states are facing record state revenue shortfalls.
Realizing the service, infrastructure, and community economic impacts of the loss of federal funds if states cut back on their Medicaid spending, governors are aggressively supporting initiatives in Congress that will increase the federal match rates. Governors are also aware that there are serious implications regarding the safety of patients, cooperation of unions and loss of accreditation for Medicaid funds as state hospital staff cuts reach dangerous levels. Proponents of an FMAP increase contend that increased federal support will temper the need for drastic cuts in Medicaid programs.
NAMI should support congressional legislative efforts to increase FMAP in 2003, and work closely with the National Governors’ Association, Association of County Commissioners and Association of State Legislators, as they work to increase federal Medicaid matching rates.
2. Medicare Prescription Drug Benefit
NAMI should closely monitor and support appropriate, emerging legislative initiatives to expand prescription drug coverage for Medicare beneficiaries. State pressure to control prescription drug spending will mount in the absence of a Medicare drug benefit.
Many states must pay the expense of drug assistance programs for Medicare beneficiaries who do not have incomes low enough to qualify for Medicaid. They must also provide the state match for dually eligible recipients under Medicaid. The federalization of prescription drug expenses for these groups through the provision of a Medicare drug benefit has profound implications for state budgets and for the Medicaid program.
3. Support System-Wide Health Care Reform
The Task Force supports systemic health care reform to address the coverage, cost and quality problems in the health care delivery and financing system.
NAMI should monitor systemic health care reform initiatives and support those that lead to better access to the most effective treatments. NAMI should participate in appropriate hearings and meetings addressing mental illness system reform and health care system reform. These two initiatives are inextricably intertwined.
Specifically, as a part of mental illness system reform, an information and tracking system should be established to support officials (e.g., a physicians), who are responsible, for monitoring individuals served and individuals denied service. It is critically important that a risk management type-officer be held accountable for monitoring and keeping appropriate records, otherwise reform efforts will be slowed.
There must be better data collection processes at the state level, with federal oversight, so that a reasonable evaluation of the system of care can occur.
NAMI should continue to press the Center for Medicaid and State Operations within the Centers for Medicare and Medicaid Services, to provide written guidance to state directors advising them of both their legal authority to create carve outs for medications for severe mental illnesses and the policy justification for such a measure.
We believe that such guidance is consistent with federal Medicaid law and the current Administration’s policy with respect to access to treatment for people with disabilities.
NAMI supports increased research budget allocations to the National Institute of Mental Health. That research will develop a better understanding of access to services and treatment as well as the potential impact of the new generation of psychotropic medications. It would enable NAMI and other advocates to identify evidence-based practices that should shape public policy recommendations.
NAMI also supports increased funding for the Agency for Healthcare Research and Quality (AHRQ) initiatives that translate research into evidence-based practices. AHRQ should sponsor research on newer psychotropic medications compared to older medications, so patients receive medical care based on the best available scientific knowledge.
NAMI should monitor the TMAP initiative (see below) to determine if its protocols can lead to more effective and more cost-effective, prescribing practices.
1. Exemption of Psychotropic Medications
2. Monitor and Participate in the Budget Process – "Do Not Balance State Budgets on the Backs of Vulnerable Populations"
3. Pharmaceutical Pricing
Notification, Grievance and Appeals Procedures
Additional advocacy efforts should insist on procedures to protect Medicaid recipients with severe mental illness from harm. The following actions are recommended:
1. Class-Action Suits
It is clear from presentations to the Task Force, that Medicaid prior authorization programs are high risk cost containment strategies and they are not an effective management strategy based on private sector experience.
It is clear to the Task Force that the consequences for people with severe mental illness will be devastating if Medicaid prior authorization programs become more commonplace.
Prior authorization programs may help state Medicaid programs control their budgets in the short term, but unintended consequences such as increases in the costs of hospitalization and incarceration in the criminal justice system will offset any savings.
Further, the Task Force heard presentations that supplemental rebate programs are confusing to consumers and physicians because they may not be aware of when a drug is covered or not at any given time.
Therefore, NAMI should closely track state supplemental rebate reform initiatives and exclusions from formularies as part of its overall legal strategy. NAMI should consider participating in class-action suits that would oppose restricting low-income Medicaid clients’ access to prescription drugs through burdensome prior authorization requirements.
NAMI should consider filing amicus briefs and should support efforts to maintain access to treatment through other court actions.
2. Align with Appropriate Groups – Build Coalitions
NAMI should work with broad-based coalitions of consumers, providers, legal rights groups, other health care advocacy organizations, and other appropriate groups to support such initiatives. Establishing short-term broad-based coalitions with interest groups who have similar objectives regarding access to prescription drugs can enhance NAMI’s effectiveness on the access issue.
Support Polypharmacy Education Programs
Massachusetts Medicaid and Mental Health Departments have introduced a voluntary polypharmacy review process, with medical service provider education and compliance tracking, as an alternative to a preferred drug list.
By educating prescribers and applying prior authorization procedures to polypharmacy practices for which there is minimal or no evidence base, Medicaid agencies may be able to improve care and moderate increases in expenditures for psychotropic medications.
The Task Force heard that recent research points to significant physical health risk to patients who are taking multiple psychotropic medications. The Massachusetts approach is an attempt to change the clinical culture and to actively engage physicians in a dialogue about prescribing practices.
NAMI should support adjunctive pharmacy, which is defined as the use of an antipsychotic medication with one or more additional psychoactive medications (including another antipsychotic) when monotherapy options have been exhausted or specific psychiatric symptoms are being targeted.
Support and Expand Development of Explicit Protocols
NAMI should encourage the use of clinically tested medication algorithms to ensure the utilization of evidence-based medication practices. The Texas Medication Algorithm Project (TMAP) has produced treatment algorithms (including prescription drug therapy) for three serious mental illnesses – schizophrenia, major depressive disorder and bipolar disease. The paradigm has been adopted in other states. NAMI should support the continued development and evaluation of the efficacy of TMAP as an alternative to Medicaid cost containment strategies.
Cost containment within the Medicaid program for medications to treat mental illnesses is an irrational process. There is no template. Solutions tend to vary by state as all politics is local and Medicaid programs differ state by state. It is critical that advocates get to the table to help policymakers connect the dots. It is important to remember that not all access policy changes are legislative. Much work occurs within appointed Drug Utilization Review and Pharmacy and Therapeutics Committees and in negotiation with governor’s and their staff members.
1. Work with state and county policymakers
Advocates should contact their legislators, county commissioners, mental health directors and other local stakeholders to collaborate in engaging state Medicaid agencies on the access issue. It is important to hold policymakers accountable for the risks and offsets caused by the Medicaid access shell game.
2. Work the Media
Advocates should contact the media’s health care reporters to discuss the potential implications of impeding access to prescription drugs. It is important to define and publicize the impact of cuts and restrictions on consumers and families.
It is a mile into the woods and a mile out. The threats in Medicaid to access to the "new generation" of medications to treat mental illness will continue over the summer and fall and into 2004. It is critical that advocates form and sustain diverse partnerships and alliances to educate the media and policymakers as to what is good evidence based policy.