The art of prescribing drugs for the mentally ill is a pharmaceutical ballet.
Need the right dosage. Need the right frequency. Need the right mix of drugs.
Off a little here or there, and the patient could suffer even more, living an emotionally uneven life that could lead to a hospital stay, a run-in with police or perhaps even suicide.
Mindy Baccus of Topeka knows the roller-coaster ride well. It took her five years and more than 20 different medications to find the mix that would help her combat a bipolar disorder first diagnosed 13 years ago.
“It’s a lot of trial and error to find what the right calibration is,” she said.
Now she’s staring down a new battle, this time with Kansas health regulators who want to more tightly control access to mental health drugs for Medicaid patients.
Baccus, 35, worries that the government is trying to interfere in the relationship with her doctor and pharmacist, possibly upsetting the delicate drug recipe that helps her live as normally as possible.
“It’s working, and I just don’t want anybody to mess with it,” Baccus said. “Every one of my drugs is at risk. I can see they’re at risk.”
During this legislative session, state health regulators have been working to repeal a 2002 law prohibiting the state from regulating mental health drugs used for treating Medicaid patients. The state, however, can regulate other drugs for treating heart disease, high blood pressure or cancer.
The state is trying to move “from the Wild West of behavioral health care drugs, where anything can be prescribed at any time with little oversight,” said Sara Belfry, spokeswoman for the Kansas Department of Health and Environment.
Repealing the law would give the state the ability to limit access to drugs that could pose safety risks or be more expensive by requiring prior authorization for prescriptions.
It could potentially save the state about $7 million, a figure hotly contested by mental health advocates.
“These are very powerful drugs with significant side effects,” Republican state Sen. Mary Pilcher-Cook said during the floor debate on the proposal. “It’s so important that we put the health and safety of Medicaid patients first.”
However, the Senate refused to repeal the law, voting it down 25-15 late last month after questions arose about whether Medicaid patients would be adequately safeguarded by the legislation.
Democratic state Sen. Laura Kelly of Topeka urged lawmakers against rushing forward with the proposal until health officials adequately answered the concerns from mental health advocates.
“How many of you would really trust going into a contract … and not have any of the details of what that contract spelled out?” Kelly asked her Senate colleagues. “We wouldn’t do it. We shouldn’t ask any of our stakeholders to do it either.”
The state promised to put protections in place for Medicaid patients, such as not limiting access to drugs for anyone who was stable on a current drug regimen and extending the time for filling an emergency prescription.
But lawmakers wanted more specifics, saying the bill was too open-ended and gave state health officials too much latitude.
“They wanted to have a better idea of how this would affect treatment for people in their districts,” said Kyle Kessler, executive director of the Association of Community Mental Health Centers of Kansas.
Republican Gov. Sam Brownback’s administration continues refining the proposal with the hope of bringing back some variation of the bill, maybe as early as this week.
State health regulators see the bill as imperative, more for ensuring health and safety than trying to cut Medicaid costs.
Two years ago, the state moved more than 300,000 Medicaid consumers to a managed care system known as KanCare run by three private companies. Brownback made the move to rein in the growth of Medicaid spending.
The effort to regulate mental health drugs is not unique to Kansas or states with cash-strapped Medicaid programs, experts said.
“Where Kansas is trying to go is right in the wheelhouse of most other states,” said Matt Salo, executive director of the National Association of Medicaid Directors.
“They really are not trying to make proper drugs hard to get for the people that need them,” Salo said. “They really are trying to provide thoughtful oversight, and that’s what most other states are trying to do as well.”
Drug spending is big money in the state’s $3 billion Medicaid program. Pharmacy spending for the Kansas Medicaid program totaled $382.4 million during 2013. About a quarter of that amount — $94 million — was for mental health drugs.
State officials, however, emphasize data showing that many children on Medicaid are on five or six powerful drugs for treating mental illness.
Their case is based partly on a 2009 study done by the University of Kansas School of Social Welfare examining mental health drug prescriptions for Medicaid patients under the age of 18 during fiscal year 2008.
Of the 18,000 children surveyed, about a third were on two or more psychotropic drugs. About 500 children were on four drugs, and about 160 were on five drugs or more. About a third of the children on five drugs didn’t have a mental health diagnosis or an outpatient provider.
State officials worry about over-prescribing mental health drugs for such a young population, with side effects that lead to obesity, diabetes, high cholesterol and a neurological disorder that produces involuntary body ticks.
“All of the people who are prescribing these medications have no intent to harm,” said Kansas Health Secretary Susan Mosier. “But there are cases where harm is being done.”
This is not the first time the issue has surfaced in Kansas. When Democrat Kathleen Sebelius was governor in 2008, state health officials pointed out that expenditures on mental health drugs were growing faster than other classes of drugs. They, too, expressed concern about the side effects of the drugs.
They estimated that putting mental health medicines on a preferred drug list and requiring prior authorization for prescriptions would save the state about $800,000, far less than what is estimated today.
While state regulators emphasize safety and health in making their case for repealing the law, skeptics see the policy change as being driven by dollars — especially with the budget crisis facing the state following income tax cuts.
Critics say the Brownback administration needs the savings to help balance the budget. They also argue the savings are far less than what’s estimated, pointing out that one brand-name drug blamed for increasing costs will go generic next month.
Mental health advocates agree there are undoubtedly cases where patients are over-prescribed with medication.
They believe there are other ways the problem can be dealt with short of changing the law, possibly by educating physicians or even reporting over-prescribing doctors to the state Board of Healing Arts.
“There are certainly some cases where over-prescribing takes place, and those should be curtailed, but not with a sledgehammer,” said Rick Cagan, executive director of the Kansas chapter of the National Alliance on Mental Illness.
Some studies have shown that clamping down on access to mental health drugs can end up costing more money.
Last month, the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California issued a paper examining the implications of restricting access to psychiatric drugs.
The paper concluded that restrictions such as prior authorization or requiring patients to try cheaper drugs first can disrupt treatment and cause patients not to adhere to their drug regimen. In turn, the report found an increased likelihood of hospitalization, homelessness and incarceration.
“It’s been shown to cause people to give up and stop taking their medications altogether,” said Seth Seabury, a fellow at USC’s Schaeffer Center.
That’s just what frightens Baccus. She worries that the new law giving the state more regulatory control could force her off some of her medications, which could change her world.
“I want to be as close to normal as possible,” Baccus said. “And when I don’t have those medications or I don’t have medications that work or I don’t have enough medications, I am either miserable and suicidal or have to spend time in the hospital.
“It’s just really scary.”
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