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Advocates say drug rule may be harmful

They are closely watching a new Medicaid policy that in July would restrict access to mental health medications.

By ALISA ULFERTS
Published May 23, 2005


TALLAHASSEE - Harry Monier had to try seven different antipsychotic drugs before he found one that worked.

It took almost 10 years, multiple hospitalizations and a couple of stints in jail before a psychiatrist hit on the right drug combination.

Now Monier says he leads a "happy, joyous and free life" with his wife and three children, despite having severe and persistent bipolar disorder.

"If you don't see me in jail, I'm doing good," the Hollywood resident said.

But Monier worries about what will happen come July 1 when a new state policy restricting access to mental health drugs covered by Medicaid kicks in.

Under the new policy, mental health drugs will have the same restrictions as other drugs covered by Medicaid, limiting patients to the least expensive medications.

Monier says that could be disastrous because not all drugs work the same for people with the same diagnosis. During one of his hospitalizations he was amazed that the patient who shared his room and his diagnosis was responding well to a drug that had made Monier violently ill.

"My body's not taking it but the guy in the hospital bed next to me swears by Depakote," Monier said, referring to a drug used to treat bipolar disorder and epilepsy. He's not the only one worried.

Mental health experts across the state are watching closely to see what will happen to impoverished psychiatric patients under the new system. Many states exempt mental health drugs from cost restrictions, but a handful don't. Florida lawmakers say the new policy will help rein in Medicaid costs, which swallow a quarter of the state budget. Prescription drugs alone cost the state more than $2.5-billion.

"Medicaid is the Pac Man of the budget," said Sen. Durell Peaden, R-Crestview, who shepherded the Medicaid changes through the Senate.

The new restrictions are part of Gov. Jeb Bush's larger plan to redesign Medicaid into a managed care program run by HMOs and other private health networks. Lawmakers approved pilot projects this year to study the impacts of such a transformation.

But patient advocates say the new drug policy could harm patients and cost hospitals.

If doctors aren't allowed to prescribe the antipsychotic drugs they think have the best chance of success, the patient's symptoms could worsen, possibly leading to hospitalizations and, ultimately, unemployment or even jail, said John Bailey, incoming president of the Florida Psychiatric Society.

"It's a short-sighted policy that ultimately will cost the state more," Bailey said. "The best decision and the most economical decision is whatever the physician writes on the prescription pad. Anything else is second guessing."

Under the new policy, Medicaid will cover the least expensive drugs in each drug classification. Patients are limited to four brand-name prescriptions per month, plus four generics. Anything more requires prior authorization from the state.

State health administrators have suggested Medicaid patients who are on medications that won't be covered might be grandfathered in. They're looking at other ways to give patients an avenue of appeal. But patients and their advocates are left to wait and worry.

New Medicaid psychiatric patients will have to try the cheapest drug first. If that fails, then they can try the second cheapest drug and so on until they work their way up to the drug that works.

That frightens mentally ill patients, said Susanne Homant, director of the Florida chapter of the National Alliance for the Mentally Ill, or NAMI. Even non-Medicaid patients worry, partly because they know if their disease worsens they might have to go on disability and rely on public sources of treatment.

Sen. Walter "Skip" Campbell, D-Tamarac, has studied the issue of mental health drugs for foster kids, and he is not completely comfortable with the restrictions. Still, he's willing to give the policy a chance.

"I do have reservations but I think there are a lot of protections in place," Campbell said. "But we have to start somewhere and if necessary we can come back next year and fix it," he added.

This is the second year in a row lawmakers have restricted mental health coverage under Medicaid. Last year they ended an exemption that let Medicaid patients whose regular care was managed by an HMO get psychiatric services outside their HMO's network. Mental health advocates argued against the change, saying many Medicaid psychiatric patients already had established relationships with their community mental health providers.

The repeal of these extra protections coincides with a lessening in recent years of the stigma attached to mental disorders. And that's no accident, says Steven Buck, who directs state policy for NAMI.

New medicine means more psychiatric patients can live at home and be treated as outpatients instead of institutionalized.

"Now we understand that the people who have these illnesses can recover and be productive. It's a paradigm shift," Buck said.

But it's not without cost, Buck said. The more mental illnesses are understood to be treatable illnesses, the more states are inclined to shift responsibility to private, employer-based insurance, Buck said. Not all plans will cover mental health, which is why Buck says it's important for the public mental health system to remain comprehensive.

Florida's system is anything but comprehensive, according to the council overseeing it. The Florida Substance Abuse and Mental Health Corporation, created by the Legislature two years ago, calls the system extremely "fragmented."

Public mental health services are scattered across no less than four state agencies: the Agency for Health Care Administration and the departments of Children and Families, Juvenile Justice and Corrections. More than 200,000 Floridians, including 41,000 children, are seriously mentally ill but don't get the health services they need, the council says.

Florida ranks 47th in the nation for per-capita mental health spending, according to NAMI.