Kansas Health Institute | Information For Policy Makers. Health for Kansans.

TOPEKA — The Kansas Health Policy Authority has tried for years to persuade legislators, drug companies and mental health advocates that prior authorization screening for Medicaid mental health drug prescriptions would improve patient safety and cut state costs.

So far, the agency has not had much luck.

But here is a history of some of the agency’s behind-the-scenes efforts:

In 2006, the agency hosted the Comprehensive Neuroscience Project (CNS) that monitored prescription patterns for mental health drugs, let physicians know when they appeared to be prescribing more drugs than their peers, and offered them training and consultation.

The project, which ended in December 2009, was paid for by drug manufacturer Eli Lilly.

Health policy authority officials said the program ended because Eli Lilly chose to no longer fund it.

But a spokesman for the drug company said the money was withdrawn because the health policy authority signaled it was no longer interested after it became clear that the project would not usher in the prior authorization system that the agency desired.

“Not realizing the full potential”

“The health policy authority was not realizing the full potential of the program and was not interested in moving forward with it,” said Scott MacGregor, a spokesman for Eli Lilly. “They were, however, supportive of repealing the statutory access protection,” he said, referring to the 2002 state law that exempts from restrictions any prescription for mental health drugs paid for by Medicaid.

Though the project was funded by Ely Lilly, it was carried out by an independent, third-party company.

MacGregor said it saved the state about $1.7 million “in behavioral pharmacy cost avoidance,” almost as much as the $2 million that health policy authority officials say could be saved with prior authorization.

Andy Allison, executive director of the health policy authority said the program revealed “quite a number of prescriptions that appeared to be outside the norm,” but did little to deter physicians from putting children on drugs that “were marginal or not clear cut in their benefits.”

Though the agency has not disputed Eli Lilly’s claim of $1.7 million in savings, it issued a report in January 2009 that questioned the program’s effectiveness and “similar retrospective education efforts.”

In essence, the agency questioned whether the savings were the result of the program or some other prescribing trend.

Despite its dim view of the program’s effectiveness, the agency has asked Ely Lilly to renew funding for the educational portion of the project.

“The most effective pharmacy management programs we see in Medicaid around the country combine provider education with more direct tools that private insurers use, such as prior authorization,” Allison said. “The Legislature had directed us to pursue funding for the educational piece alone and we have done that. Eli Lilly has now told us they will no longer support the program. At this point, I would have to say that the fundamental questions we identified nearly two years ago remain unresolved.”

“The health policy authority had a system that was working,” said Mike Hammond, executive director of the Association of Community Mental Health Centers, referring to the CNS project. “But it wasn’t doing what they wanted, which was to go to some kind of formulary. That’s what this is about. It’s about cutting costs. They say this is about safety and children, but nobody believes them.”

Appropriate use

Last year, the health policy authority formed the 15-member Mental Health Prescription Drug Advisory Committee to again look for ways to address safety concerns and, perhaps, curb costs.

The agency asked the committee to consider endorsing prior authorization for mental health drugs.

“We did so because to my knowledge, changes in reimbursement policy have been the only documented strategy that’s had any impact on prescribing behavior,” Allison said. “It doesn’t prevent (mental health drugs) from being prescribed, it creates a pause in the process that can be used to assure appropriate use.”

But mental health advocates and the drug companies remained staunchly opposed.

“We are absolutely opposed to removing the exemption,” said National Alliance for the Mentally Ill- Kansas Executive Director Rick Cagan. “The people we’re talking about here are much more vulnerable than the general population.”

At its May meeting, the advisory committee expressed informal support for starting an educational program aimed at making sure physicians and advance nurse practitioners understood the risks of prescribing adult drugs for children, essentially calling for revival of the project that the health policy authority had criticized and which Eli Lilly chose to no longer fund.

In August, the health policy authority suspended the committee, noting that efforts to find alternate funding for an educational program had floundered and there was no reason for the committee to meet further because its chief role was overseeing an educational program that no longer existed.

Very real economics

“I guess you could say we’re in sort of an analytic phase,” said Dr. Michael Burke, chairman of the advisory committee. Burke is a psychiatrist and director of medical education at the University of Kansas School of Medicine-Wichita.

He said some in the group were strongly opposed to prior authorization. Others saw its logic.

“People don’t like to hear me say this, but the economic side of this is very real,” he said. “At some point we’re all going to have to realize that we’re dealing with a fixed pool of resources, and that the drugs we’re talking about here are extremely expensive.

“So if the decision is to keep doing what we’re doing, we’re going to end up, hypothetically, treating one person instead of 10 because that’s all the resources will let us do,” Burke said. “The goal, I’d say, should be for us to be good stewards of the resources and to look for ways to serve the 10 instead of the one.”

Prior authorization could do that, he said, but for that to happen, the law would have to be repealed; and for that to happen, advocates would have to trust the health policy authority.

Today, that trust isn’t there.

Wishing to go back in time

“As a psychiatrist, I can tell you that people with a mental illness have taken a lot of hits over the years,” Burke said. “When the state hospital closed, they were told, ‘Oh, don’t worry, the (hospital’s) resources will be funneled into outpatient services,’ and that never happened, and then, on the private insurance side of things, managed care has put them through all kinds of additional hoops and hurdles to receive services. So when you hear them say they’re suspicious (of the health policy authority) there’s a reason.”

Topeka State Hospital, once the largest of the state’s four inpatient psychiatric hospitals, was closed in 1997.

Dr. Eric Atwood, a Topeka child psychiatrist, was on the advisory committee. He also helped oversee the Eli Lilly-sponsored program.

“I wish there was a way to go back in time so this could have been handled different from the way KHPA (the health policy authority) has handled it,” Atwood said. “I’m convinced that if the goal had truly been patient safety and high quality care, a partnership would have developed and there would have been cost savings. But in my view the main issue was cost with safety being the flag that was flown. The partnership, unfortunately, hasn’t developed.”