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State's Drug Formulary Rules Cause Concern for Psychiatrists

Tennessee psychiatrists are organizing to track the impact of changes to the Tennessee Medicaid program, and Florida will soon shift Medicaid beneficiaries to managed care plans.

New rules governing which drugs are available to new TennCare enrollees diagnosed with severe mental illness are likely to have a major negative impact, according to psychiatrists in the state.

TennCare, the Tennessee Medicaid program, instituted a new preferred drug list at the beginning of December that made only five atypical antipsychotic medications available for new enrollees diagnosed with severe mental illnesses.

Psychiatrists worry that the new rules, which do not affect the 60,000 Medicaid recipients with psychotic conditions already enrolled in TennCare, will lead to increased health risks and noncompliance.

Radwan Haykal, M.D., president of the Tennessee Psychiatric Association (TPA), said factors that could lead to noncompliance for those taking antipsychotic medications include the induction of disabling side effects and the lack of clear improvement from medication. The Medicaid drug restrictions could increase the occurrence of those problems and others because physicians will have a limited ability to match the best atypical antipsychotic with individual patients' needs.

"The compliance rate is a problem with any chronic disease, and this policy will only add to that problem," Haykal said.

The TennCare change requires psychiatrists to prescribe one of the five preferred antipsychotic drugs—generic clozapine, Fazaclo Odt (an orally disintegrating form of clozapine), ziprasidone (Geodon), risperidone (Risperdal), and quetiapine (Seroquel)—for four weeks before they can try a four-week trial of another preferred atypical antipsychotic medication. Only after both attempts will they be allowed to try one of the six nonpreferred antipsychotic medications—aripiprazole (Abilify), clozapine (Clozaril), other risperidone versions (Risperdal M-Tab and Risperdal Consta), and olanzapine (Zyprexa and Zyprexa Zydis).

The change came despite a unanimous recommendation against it from the TennCare Pharmacy Advisory Committee. TPA and APA maintain that physicians must have the final say on the use of medicines that treat mental illness.

TPA has created partnerships with other Tennessee health organizations to monitor changes in TennCare enrollment and patient access to medications under the new regulations. They will check for increases in suicide rates, rises in hospital recidivism, and higher noncompliance, among other factors, Haykal said.

TPA has also launched an effort to educate state lawmakers on the impact of the TennCare changes and the sensitivity of patients with severe mental illness to prescription changes.

TennCare officials said the changes were meant to add cost considerations to physicians' prescribing patterns.

Florida is also making Mediciaid changes. Federal regulators approved a Florida Medicaid pilot program to shift thousands of Medicaid recipients into managed care. Proponents claim the program would provide better care through a transfer of responsibility to networks of doctors and help control escalating Medicaid costs.

The state legislature must approve the program, which aims to start in two counties in July 2006. Gov. Jeb Bush (R) planned to call a special legislative session in December to consider the proposal.

Under the plan, Medicaid-eligible residents in Broward and Duval counties could choose a health care plan, which would include health maintenance organizations (HMOs) and networks established by doctors and hospitals. The existing Medicaid program locks HMOs into a basic plan with coverage of identical, federally mandated services. The proposal would allow the HMOs to tailor their plans to specific beneficiary populations.

Psychiatrists and mental health care advocates said they were concerned that hospitalizations could spike if HMOs cut optional mental health treatments that some Medicaid recipients now receive in Florida.

John Bailey, M.D., president of the Florida Psychiatric Society, said his organization is lobbying the legislature to ensure that the program does not impede treatment access for Medicaid patients with mental illnesses.

"We're hoping to have a positive impact on the changes because at the outset it sounds like it could have a big downside—putting HMOs in the role of managing mental health could further impede access," Bailey said.

The existing system has room for improvement, Bailey said, because patients with mental illness are limited by low reimbursements to treatment from community mental health centers, instead of private psychiatrists and treatment programs.

Florida's largest health insurance carrier, Blue Cross/Blue Shield of Florida, announced it would not participate because it was "not prepared to devote the kind of resources needed to succeed."

The Tennessee preferred drug list is posted at <https://tennessee.fhsc.com/Downloads/provider/TNRx_PDLquicklist_20051101.pdf>.

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