APA Fights Attempt to Limit Access to Psychoactive Drugs

I was reminded of the ever-changing nature of psychiatric practice after reading a recent e-mail exchange between an APA member and a fellow Board of Trustees member. The e-mail touched on recent developments that affect our practice and our patients. Specifically at issue are the trends toward the increasing managed care–like management of pharmacy benefits and the increased assault on inpatient psychiatric care.

It is not necessary to elaborate on the utility of medications in contemporary treatment. Yet, it is undeniable that costs for medications have increased at a rapid rate over the last decade. This is attributable to a number of factors including increased costs of the new drugs and, even more so, to the large increase in the use of medications. Not surprisingly, an escalating cost curve has drawn the attention of third parties who manage and or pay for these benefits. This has resulted in a variety of developments that require our monitoring and intervention.

For example, state Medicaid programs are now developing preferred drug lists, which often incorporate so-called “fail-first,” and other clinically inappropriate mechanisms. APA, in collaboration with the National Alliance for the Mentally Ill and the National Mental Health Association, has been significantly involved in the 50 states where we have sought appropriate exemptions and/or management mechanisms for psychotropic drugs.

This effort will rapidly segue into our ongoing advocacy efforts regarding the new Medicare prescription drug program under Part D. Under the program, effective January 1, 2006, some 7 million “dual eligibles” or patients covered by both Medicare and Medicaid will be transitioned to coverage under the Medicare program. The challenges to assure access to clinically appropriate medicine under the Medicare program are daunting—such as how formularies will be defined and the continuity of care for patients stabilized on a drug regimen. Moreover, we are increasingly faced with the new position of so-called evidence-based standards that will govern the access to drugs that are deemed cost-effective and clinically appropriate.

Another area of concern to APA is the growing evidence around the acute-care and long-term-care bed shortage. The bed-shortage issue will be compounded by a number of recent developments (Psychaitric News, December 3, 2004). A new prospective payment system (PPS) for inpatient psychiatric care was implemented on January 1. While APA continues to analyze the impact of this new payment system, one fact is clear: by definition, the new PPS methodology will redistribute the monies paid under Medicare across all hospitals currently caring for inpatient psychiatric patients.

Concern for inpatient psychiatric care under Medicare is furthered by the aggressive posture of several of the Medicare fiscal intermediaries who have recently put into place overly proscriptive documentation requirements for inpatient psychiatric care that will impact every region of the country. These new requirements go well beyond the well-established standard of practice for documenting inpatient services without providing evidence to support the need for this type of documentation.

APA continues to work with the Centers for Medicare and Medicaid Services, as well as with the fiscal intermediaries, on issues relating to inpatient psychiatric care.

More information on APA's activities on these topics can be found on our Web site at<www.psych.org>. APA continues to provide individualized assistance through the APA Managed Care Help Line at (800) 343-4671 or<[email protected]>. Staff can provide assistance on a number of issues including pharmacy benefit management, CPT coding and documentation, and Medicare and Medicaid. Your calls also provide valuable information concerning current trends and can serve as an early warning system to APA on practice-related issues. As I've said before, your voice is one of the most important aspects of your membership and provides the basis for the work we do. ▪