VA Prescribing Policies Puzzle Some Psychiatrists

The General Accounting Office (GAO) answered “yes” to one question posed by the House Committee on Veterans’ Affairs and “sometimes” to a second question.

In a report issued in April, the GAO found that the Department of Veterans Affairs’ (VA) clinical guideline for prescribing atypical antipsychotic drugs is consistent with medical community practices for managing serious mental illness and that implementation of the guideline is “generally sound” in terms of ensuring that prescribing decisions are based on a physician’s clinical judgment.

One impetus for the report was the reaction to a VA proposal last year that doctors could prescribe olanzapine only after veterans had undergone 10-week trials of risperidone or quetiapine. These two drugs are less expensive and less frequently prescribed. All are used to treat schizophrenia.

That proposal, in turn, resulted from escalating costs of prescription drugs, particularly antipsychotics and antidepressants. In Fiscal 2001, the amount spent for antipsychotic drugs jumped 29 percent to $158 million, or 7 percent of the VA’s total drug costs.

Antipsychotic drugs—both typical and atypical—are the VA’s third most expensive class of drugs. Its most expensive class of drugs is antilipidemics, and the second most expensive class is antidepressants.

According to the February 13 Wall Street Journal, the National Alliance for the Mentally Ill successfully lobbied for language in the VA’s 2002 appropriations bill that would prevent implementation of the proposed “fail-first” policy until the National Institute of Mental Health concludes a study scheduled for completion in 2006 on the relative effectiveness of atypical antipsychotics.

The conference report on the VA’s Fiscal 2002 appropriations directed the secretary of Veterans Affairs to communicate to physicians the existing VA policy that physicians are to use their best clinical judgment when choosing atypical antipsychotic drugs (HR Rep. No. 107-272, at 56, 2001).

In response, the VA’s undersecretary for health issued a notice on January 16 reiterating the conference report’s message.

Guideline for Prescribing Antipsychotics

The VA’s prescribing guideline for atypical antipsychotic drugs stipulates that a physician is to prescribe risperidone or quetiapine for the first episode of psychosis or chronic psychosis in relapse if no patient-specific issue suggests another drug. The guideline, however, states that “selection of therapy for individual patients is ultimately based on physicians’ assessment of clinical circumstances and patient needs. . . . [T]he guidelines are not intended to interfere with clinical judgment.”

The GAO found that the guideline is “sound and consistent with published practice guidelines commonly used for public and private health care systems.”

According to the report, the prescribing guideline is similar to the four clinical guidelines most widely accepted by public and private health systems—the Texas Medication Algorithm Project; the Expert Consensus Guidelines Series: Treatment of Schizophrenia; the Schizophrenia Patient Outcomes Research Team; and APA’s Practice Guideline for the Treatment of People With Schizophrenia.

In addition, the GAO cited a study in the October 1999 Journal of Clinical Psychiatry that concluded that risperidone, quetiapine, and olanzapine are comparable in efficacy, safety, and patient tolerability.

All atypical antipsychotic drugs are on the VA’s national formulary, except ziprasidone, which is available through nonformulary approval processes.

Some Psychiatrists Feel Pressure

The GAO contacted pharmacists in each of the VA’s 22 Veterans Integrated Service Networks (VISNs) and visited or contacted 14 facilities in eight of them to determine whether the guideline was being followed. They also surveyed all of the VA’s 1,723 psychiatrists via e-mail about how the guideline affected their prescribing practices. Fifty-two percent responded.

The survey indicates that the vast majority of VA psychiatrists—91 percent—feel that they are able to prescribe the atypical antipsychotic drugs that are best for their patients, but 9 percent report not feeling free to do so (see chart).

Only 66 percent of the psychiatrists, however, reported that they had seen or been briefed on the guideline. Thirty-one of the 876 psychiatrists in the survey reported that they believed prescribing high-cost atypical antipsychotic drugs could affect their performance rating.

Restrictions on prescribing were concentrated primarily in facilities in five VISNs that have established additional policies and procedures for prescribing atypical antipsychotic drugs.

In the Greater Los Angeles Healthcare System (VISN 22), 33 percent of the psychiatrists reported that they did not feel free to prescribe the antipsychotic drug of their choice. Twenty-two percent of the psychiatrists in VISN 18, headquartered in Phoenix, also reported feeling restrictions on their prescribing.

An example of a restrictive practice occurs in VISN 22. Psychiatrists must provide written justifications for prescribing olanzapine, which are reviewed by pharmacists or senior psychiatrists. For routine requests—such as those for VA patients who are already stable on olanzapine or patients who did not respond favorably to other atypical antipsychotic drugs—the pharmacist fills the prescription.

For nonroutine requests—such as those for new patients who have not previously taken atypical antipsychotic drugs—the pharmacist forwards the request and written justification to a senior psychiatrist, who reviews them and may discuss recommended treatment options with the prescribing physician. In the four months after the prescribing guideline was implemented, 11 percent of olanzapine requests were denied as part of its cost-containment procedures.

In response to the GAO report, the VA stated that it will continue to monitor routinely prescribing patterns of atypical antipsychotic drugs through its national drug utilization database to identify and address any outliers in drug usage that become apparent. It will also coordinate with clinical managers to make certain the intent of the guideline is understood by all.

The pressures to contain costs likely will continue, given reports of budgetary problems concerning provision of medical services under the VA.

On April 6 the New York Times reported that elderly veterans struggling to cope with rapidly rising drug costs are pouring into the VA’s health care system. The problem is exacerbated by the withdrawal of HMOs that provided prescription drug benefits through Medicare+Choice.

According to the Times, the number of veterans enrolled in the department’s network of clinics, hospitals, and pharmacies has doubled since the mid-1990s to 6 million. The department’s pharmaceutical costs have risen more than 160 percent in the same period, to $2.9 billion last year from $1.1 billion in 1996, while its medical budget has increased just 42 percent.

APA Medical Director Steven Mirin, M.D., testified before the House VA-HUD Appropriations subcommittee on April 16 about the need to increase funding for veterans’ health care (Psychiatric News, May 17). According to a press release, he said, “While we are encouraged by the administration’s FY 2003 proposed budget increase for veterans’ health care, APA joins with many other veterans’ groups in requesting an additional $750 million to ensure adequate funding to meet the current medical needs of veterans, particularly those with mental illness.”

The GAO report, “VA Health Care: Implementation of Prescribing Guidelines for Atypical Antipsychotic Drugs Generally Sound” (GAO-02-579), is posted on the Web at www.gao.gov/new.items/d02579.pdf. ▪