Psychiatrist Sues State Medicaid Plan Over Prior-Authorization Requirement

A Massachusetts psychiatrist has asked a state court to allow him to treat his Medicaid patients using the same standards and decision-making procedures he uses for other people he treats.

George Sigel, M.D., of Norwood, Mass., filed suit in August against the Massachusetts Medicaid program contending that its prior-authorization requirement for several psychiatric drugs is an illegal form of discrimination against patients insured through that program.

While on the books for 17 years, a rule requiring prior authorization for a group of psychoactive medications was ignored by state Medicaid officials until last May, Sigel told Psychiatric News. “It really hit us hard because [the move to enforce the policy] unfolded so dramatically,” he said.

Beginning in May, some antidepressants required prior authorization, and starting in June all antipsychotics except risperidone fell into this category (Psychiatric News, May 16, 2003).

Patients who tried to fill prescriptions for these drugs ran into a roadblock at their pharmacy, forcing them to return to their doctor before a pharmacist could dispense the prescribed medication, said Sigel. He is program director for the South Boston Behavior Health Program, an outreach program of the New England Medical Center.

“Patient advocates starting getting very nervous” about the obstacles in getting psychiatric medications, and their lobbying convinced the state program to delete the antipsychotics from the preauthorization requirement. It did, however, leave in place the Food and Drug Administration’s (FDA) dose guidelines, thus prohibiting “off-label dosing,” he noted.

The governor soon decided that the dosing restrictions for these drugs “made no sense,” Sigel said, and instructed the agency to remove them.

While he viewed this as a positive step, Sigel noted that “the problems continued regarding access to mood stabilizers and some, but not all, antidepressants.” The problem with the mood-stabilizer rule, he said, is that a physician cannot prescribe that class of drug for any “off-label” use without preauthorization from Massachusetts Medicaid.

For example, Sigel said that he has “at least 13 patients on Neurontin, and though the patients are pleased with their response,” when he requests preauthorization to prescribe the drug, “in most instances [Massachusetts Medicaid] denies it because the use is not FDA approved.”

Most of his patients are suffering from chronic and persistent mental illness and have their care paid for through Medicaid, he pointed out.

His decision to sue the agency was made much easier when he witnessed the dichotomy of reactions his patients exhibited when told about the preauthorization rules. Medicaid patients “would suddenly tense up” when they realized it was unlikely the program would cover the cost of their medication, Sigel said.

“I decided that this [policy] was a totally unnecessary intrusion into the doctor-patient relationship, and it was forcing me perilously close to committing malpractice,” he stated.

He also maintained in his court filing that these restrictions—which affect how he treats one category of his patients—forces him to discriminate against them in violation of the Massachusetts and federal constitutions.

Sigel, who is acting as his own lawyer, had asked the court to grant injunctive relief, a request the judge denied, citing the absence of a danger of immediate harm to patients. He is now waiting for the judge to decide whether his filing has sufficient merit that it can proceed to the discovery phase, in which he can obtain relevant documentation from state officials.

Sigel has not received financial help from any professional or advocacy organizations. ▪