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Psychiatrists Convince State To Modify Drug Formulary

Thanks to Michigan psychiatrists, officials have made concessions about psychotropic drugs as the state begins implementation of a Medicaid drug formulary.

Members of the Michigan Psychiatric Society (MPS) helped shape the future of the state’s new drug formulary for Medicaid patients by persistence, close attention to detail, and an inclusive approach to solving problems.

The high-profile formulary was touted in the December 7, 2001, Wall Street Journal as an "experiment that takes dead aim at the drug companies’ freedom to set prices" (Psychiatric News, January 18).

A committee of physicians and pharmacists chose so-called best-in-class drugs in 40 categories covering a range of illnesses across all of medicine. The formulary policy stipulated that if a physician wanted to prescribe a drug not on the list, he or she must "call a state technician and get approval," which would be granted only if the drug was considered "medically necessary."

After a legal challenge by the Pharmaceutical Research and Manufacturers of America, the Michigan Court of Appeals on January 18 lifted a circuit court’s order that blocked the state from implementing the formulary.

The state contracted with First Health, a pharmaceutical benefits management (PBM) company to administer the formulary for Medicaid fee-for-service patients. The 19 Medicaid HMOs, called qualified health plans (QHP), will administer the formulary for psychotropic classes of drugs for their Medicaid managed-care patients, many of whom receive services from the community mental health program.

"Problems of communication and coordination immediately became apparent," said Jonathan G.A. Henry, M.D., medical director of the Clinton-Eaton-Ingham Community Mental Health Board.

First Health was to begin implementation of the formulary on February 1, but by late February even the steps by which a physician was to request prior authorization were unclear. The process, as outlined by state legislators in a letter of agreement, requires a call to a PBM technician, which can be followed by an appeal to a PBM pharmacist and a subsequent appeal to a physician under contract with the Michigan Department of Community Health.

First Health and many of the 19 QHPs each developed a preauthorization form, which could have resulted in physicians keeping track of 20 different methods for making requests.

Henry said that he and other medical directors of community mental health centers began hearing rumors that primary care physicians were planning to drop Medicaid patients because of the confusion, administrative burden, and need to obtain preauthorization for patients who were stable on nonformulary drugs.

An exodus of those physicians would have taxed the resources of the already burdened community mental health centers.

Henry, other members of MPS, and a coalition representing community mental health centers brought their concerns to state officials.

"We needed to get everyone at the table," he said. "We involved First Health, the HMOs, primary care physicians, hospitals, as well as psychiatrists."

The most significant victory was a grandfathering in of Zoloft, Celexa, Prozac, Luvox, Effexor XR, Aricept, and Durgesic Patch for patients who were using the drugs prior to March 1. State officials were persuaded by the argument that it would be pointless to take a patient off a medication that works well.

A series of meetings resulted in significant progress in terms of administrative procedures and coordination. The medical personnel, for example, pointed out that procedures were necessary to ensure that patients being discharged from psychiatric hospitals were able to continue with their medication.

The collaborative enterprise led to an effort by MPS to explore ways to provide training and education about the use of psychotropic medications. The activities will be targeted to primary care physicians, as well as community mental health psychiatrists.

What can psychiatrists in other states learn from the Michigan experience? "Be proactive and work collaboratively," said Henry.

They may need to apply those lessons soon. In its February 27 edition, the Wall Street Journal reported that a formulary similar to Michigan’s was part of a budget proposal vetoed by Minnesota Gov. Jesse Ventura (I). The proposal is expected to appear in a later compromise bill.

The National Conference of State Legislatures found that as of October 2001, 26 states had passed some type of pharmaceutical regulation law (Psychiatric News, March 1).

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