Dr. Mark Bradshaw, a psychiatrist for All-Care Health Plan, a coordinated care organization in Medford, testified this month in Salem that southern Oregon is a national leader in the rate at which it prescribes psychiatric medications to children.
Particularly benzodiazepines, prescribed for anxiety but carrying serious side effects and potentially lethal when mixed with other substances like alcohol, he said, has been heavily over-prescribed for both adults and children, and anti-psychotics have been inappropriately prescribed to children under five.
One rationale for Southern Oregon’s dubious distinction stems from a state law that for years has prevented the state, and now his CCO, from having much control over how psychiatric medications are dispensed for the Oregon Health Plan. All-Care and others have struggled to integrate mental healthcare with physical healthcare because they have no way of coordinating those prescribed drugs.
“They don’t want to see people suffer,” Bradshaw told The Lund Report. “When primary care providers do not have access to consulting, they prescribe in a void.”
His organization is recruiting more psychiatrists to the area, but primary care providers have often been unable to consult with a mental health specialist, and they prescribe not knowing best practices.
The Pharmaceutical Research and Manufacturers of America has successfully marketed a medication-focused approach to mental healthcare for the past two decades, but Bradshaw said many of the drugs have gone generic; it’s no longer an issue of the state’s ability to afford costly medications.
“This is not a money issue anymore,” Bradshaw said. “This is a safety issue.”
Kitzhaber Bill
Former Gov. John Kitzhaber introduced House Bill 2421 this session to change the way psychiatric medications are managed for those on the Oregon Health Plan. Two classes of drugs -- ataractics/tranquilizers and psychostimulants/anti-depressants -- have a special carve-out from the policies that govern all other prescription medications, and these drugs have almost no sideboards for the state Medicaid program.
HB 2421 would eliminate that carve-out and give CCOs the ability to manage these medications as they do other drugs.
For the coordinated care organizations to work as conceived, they must be able to integrate mental health with physical health. But currently, CCOs are not allowed to manage psychiatric meds, which are purchased through a separate process outside of their budgets. They have no easy way to track prescriptions, let alone coordinate them.
Bradshaw said that the All-Care staff, informed by a team of experts versed on best practices and an evidence-based formulary, regularly consults with physicians and nurse practitioners on the physical health drugs they manage, and discusses the patient’s treatment if it deviates from the standard treatment. Some patients will still need a specialized treatment, which their physicians can still prescribe.
Pharmaceutical Companies Work Both Sides
But the state and the CCO leaders will have an uphill battle bringing psychiatric medications under their management.
The pharmaceutical companies and their trade group, PhRMA, have used their profits to play on both sides. Pharmaceutical companies routinely spend hundreds of thousands of dollars bolstering the campaigns of Oregon politicians, including $314,000 in the past year, according to an analysis from The Lund Report released recently.
At the same time, pharmaceutical companies are the primary funder of the National Alliance on Mental Illness, and routinely provide the funding for smaller patient advocacy organizations.
In 2009, Congress prodded NAMI to disclose its funding sources, and the organization admitted that 75 percent of its resources come from pharmaceutical companies. Since that time, the national organization has publicly disclosed its funders on its website, and has continued to take the bulk of its funding from drug companies, to the tune of a few million a year.
But locally, NAMI-Oregon executive director Chris Bouneff refuted the notion that his organization is doing the pharmaceutical industry’s bidding, and, in fact, said that he has been at loggerheads with PhRMA. While the national organization provides training opportunities and educational material for the state chapter, the local organization, which pays Bouneff’s salary, raises its own funds and only 3 percent of that comes from drug companies, he disclosed.
Bouneff has proposed a middle way that he says the drug companies hate but the CCOs have also not taken seriously -- moving the budget for psychiatric medications over to the local organizations, without restricting access to patients whose mental condition requires specialized medications.
He proposed just such a bill in 2012, using PacificSource’s managed care organization in central Oregon as a pilot program, but the bill was successfully gutted through the lobbying efforts of PhRMA. At the time, the Republicans controlled the House of Representatives, and the drug companies may have had more clout than they do now.
Bouneff told The Lund Report at the time that the drug companies blocked his efforts because they wanted “free reign to influence prescribing.” But he’s also critical of efforts to give too much control to the CCOs to micro-manage patient’s medications, particularly if the 16 CCOs had the ability to set up 16 different formularies, each allowing slightly different drugs to be prescribed.
There’s a lot the CCOs could be doing now, without the legislation, Bouneff said, to link psychiatrists to primary care and to better educate their primary care providers about best prescribing practices and the dangers of certain psychiatric medications. All of this could be done without restricting access to drugs for patients. “It’s a prescribing issue. It’s not a formulary issue,” he said.
Bouneff would like to see prescribers adhere to an algorithm-based “decision tree,” which would direct patients to the best therapies and medicines based on scientific evidence, while still allowing them to detour toward non-standard medications, if that worked best for the patient.
The management of psychiatric medications is complicated by the fact that many people have experienced the outsized volatility and unpredictability that comes with drugs that affect the brain as compared to other parts of the body. “The volatility of these medications is so significant that any little hiccough has profound consequences,” Bouneff told The Lund Report last week.
Linda Dunn, a Portland mother of an adult daughter with bipolar disorder, told legislators that her daughter experienced serious problems when she was placed on a generic psychiatric medication, after she had been able to control her condition with a brand-name drug.
“These medications do not work the same as a painkiller for a broken leg,” Dunn warned.
“I absolutely agree, if a patient is on a medication that works, they should be able to stay on that medication,” Rep. Mitch Greenlick, D-Portland, told her in response. “If we pass a bill, that will be a part of it.”
CCOs Want to Delay Law
In her testimony, Ashlen Strong, the lobbyist for Health Share, a Portland-area CCO, said that the state’s 16 CCOs wanted to slow the move to manage these prescriptions, and she proposed an amendment that would call together a stakeholder group to develop a more methodical means of bringing psychiatric prescription management under the umbrella of the CCOs.
“In order to successfully transfer management of the benefit to the CCOs and avoid patient and system destabilization, the OHA should undertake a more deliberate process with meaningful stakeholder engagement,” Strong wrote.
The CCOs’ amendment would delay the effects of HB 2421 for another year and call upon a task force to report back to the Legislature this September. This nine-member stakeholder group would include a mental health consumer, two mental health providers and a mental health policy expert, although the composition of the task force would still draw a majority of its members from the CCOs and the state.
But Bouneff said he could not support the makeup of such a task force because it was stacked too heavily toward the CCOs, and it did not seem to provide enough room for the compromise he wants.
