Mental Health Drugs To Come Under Review by Central Oregon Health Council

These drugs will continue to be reimbursed by the Oregon Health Authority’s Department of Medical Assistance Programs but provide local officials with more information on the effectiveness of the medications

March 1, 2012—By July, the Oregon Health Authority is expected to begin providing real-time data to the Central Oregon Health Council, which coordinates the care of Oregon Health Plan patients in Deschutes, Crook and Jefferson counties, on the mental health drugs used by people living in that area.

Senate 1506 passed the House and Senate unanimously earlier this week, directing the Oregon Health Authority to provide data on which mental health drugs are being used, how often patients fill their prescriptions, whether they fill them as prescribed and other information relating to patients’ use of the mental health drugs.

The Oregon Prescription Drug Program, which purchases mental health drugs for some state agencies, including the Oregon Health Authority, will be responsible for sharing the data with the Central Oregon Health Council, which is made up of representatives from various provider groups and county government.

The bill applies to all mental health drugs that are currently paid for directly by the Oregon Health Authority’s Department of Medical Assistance Programs, rather than the managed care plans throughout the state, in what’s known as the mental health “carve out.”

“It is the one piece of the healthcare puzzle that’s still paid for directly by the state,” said Sen. Elizabeth Steiner Hayward (D-Hillsboro).

Chris Bouneff, the executive director of Oregon’s chapter of the National Alliance of Mental Illness (NAMI), said this “carve out” was created to protect patients and ensure that they receive the most effective medication. Also, a patient’s access to these mental health drugs will never be interrupted – even if the costs exceed the budget – the state will continue paying the bill.

Finding the right medication for a person with a particular mental illness can be difficult, Boneff said, because two people with the same mental illness can react differently to the same drug, and many drugs can take weeks or months to become effective.

“You want to be very careful about starting the person on the right medication,” Bouneff said. “Failure can be catastrophic when we’re talking about mental health drugs.”

But because the state pays directly for these drugs, a patient’s provider or their managed care plan may not know about the effectiveness of these medications until six weeks later. “That’s not helpful,” Bouneff said, particularly when providers are attempting to integrate physical and mental healthcare.

“[You] can’t achieve full coordination without seeing data about those drugs,” said Robin Henderson, acting executive director for the Central Oregon Health Council, which is made up of representatives from various Central Oregon provider groups and county government.

The bill’s supporters say the legislation, and the ability to review current data, will help physicians better coordinate the care of their patients. “Physicians need to have real time access to the data of what mental health drugs a person is taking,” said Rep. Val Hoyle (D-Portland). “It makes sense that if we’re going to integrate care that we also integrate access to information.”

Steiner Hayward believes the data sharing will be a “model for how the Oregon Health Authority can interact with [coordinated care organizations] moving forward.”

Coordinated care organizations, or CCOs, will create patient teams made up of doctors, nurses, behavioral health providers, community health workers, and other providers who will integrate physical, mental and dental healthcare for 600,000 patients on the Oregon Health Plan. The hope is that by focusing on preventive care and reducing emergency room utilization, costs can be reduced. With the passage of Senate Bill 1580 last week, the Oregon Health Authority is preparing to implement CCOs throughout the state starting July 1.

Senate Bill 1506 underwent a substantial amount of change from its original version. Originally, the bill would have created a two-year pilot program allowing PacificSource, the managed care plan in Central Oregon, to pay for the drugs themselves.

PacificSource would have used a capitated rate for these drugs—setting aside a certain amount of money, and the health plan uses a capitated rate for its other health services. There was a provision in the original bill that said that if PacificSource exceeded the costs for the drugs, the state would have stepped into and paid the difference.

“It would change who the money was flowing through. It didn’t change access, and there was a backstop,” Bouneff said.

Allowing Pacific Source to pay for the drugs, Bouneff said, would have allowed the managed care plan to analyze the cost of the drugs, as well as develop ways to improve a patient’s health so that they would be less dependent on the drugs—and thus save money.

“The thrust of the pilot was getting education out to prescribers, pharmacists and patients so people could make very informed choices,” Bouneff said. “And you had this integration of information so we could really focus on health outcomes. If you use medications strategically, a patient’s health outcomes improve and you can reduce the cost of the medications.”

But the bill received a substantial amount of opposition particularly among pharmaceutical groups, even though there was no testimony during the public hearings. Jim Gardner, a lobbyist for PhRMA, did not return a call for comment, but Bouneff said the pilot project could have affected pharmaceutical companies “free reign to influence prescribing.”

Tom Burns, the Oregon Health Authority’s director of drug purchasing, sent a letter to the Senate’s Healthcare committee saying that the Department of Medical Assistance Programs could develop a way to send data to the Central Oregon Health Council within 24 hours, instead of the typical six-week wait.

Bouneff said he and others doubt whether the Oregon Health Authority will actually be able to provide the data in a timely manner. “This is something we’ve asked the state to do, and they’ve shown no interesting in doing it.”

The Central Oregon Health Council also intends to establish a clinical advisory committee—something that was in the original bill, but not in the final version—that will look at ways to integrate information about mental health drugs, as well as how to better manage the medications, and improve a patient’s health. The council is expected to submit a report on this project during the 2013 legislative session.

Photos for this story appear courtesy of The Oregonian.

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There are now many peer-support groups in Portland: Hearing Voices Network, Empowerment Initiatives, and Mental Health Association of Oregon, where people can check in and learn ways others have used to come to emotional stability. Hearing Voices Network has also pioneered bringing the Open Dialogue method of responding, from Lapland, to Portland. This program is cost-effective with the best outcomes those of us looking have been able to find on the planet. Trieste, Italy, uses a recovery-through-work way to help, and their outcomes are also good. We need careful medication auditing, which we should be able to do, if costs are being paid for those on public assistance, in particular. It is trickier if people are using different pharmacies because of cost differences, but clients have every reason to get educated, and the internet provides a convenient library, if one learns how to use it well. Some of the new research is being done offshore, as in the example of the British research that curbed the use of SSRI's in youth. I also think it is good if large groups like Kaiser do their own research and post the results. Good will can be generated with this effort, which may make for good recruiting results, especially among the huge Baby-Boom cohort coming into Medicare age.

It is disappointing that the focus is more on cost reduction than on effectiveness. We really need to be looking at the impact of these drugs on long-term outcomes, rather than just focusing on immediate symptom reduction. All the participants in this process need to read Anatomy of an Epidemic by Robert Whitaker, which provides ample evidence that the current paradigm of symptom management both denies the reality of recovery as a real outcome, and helps to create increasing levels of psychiatric disability over time. We need to refocus on making people's lives better, in real terms like employment, education, family, and social involvement, rather than making people feel "less bad" than they did before. We save the most money when we turn mental health consumers into productive citizens, or rather, empower them to do so themselves. Medication may have a role to play, but the central role it currently occupies is costing the taxpayers billions a year and not getting the results we need. It's not surprising that PharMA opposes even this moderate level of oversight. When we see opposition to the concepts of recovery that Anonymous and I are promoting, it's not hard to figure where it's coming from. Because let's face it, while permanent disability would be considered a bad outcome by both consumers and those who pay for psychiatric care, permanent disability does benefit one group - the pharmaceutical companies! Let's stop letting PharMA lobbying determine our policies. Let's have our policies be driven by real outcomes that matter to our consumers and society. While Big Pharma's profits may suffer, the rest of us will be a lot better off! --- Steve

The larger issue here is the plain view of fragmented payment systems that obstruct courses and choices of care, which are not resolved by the new move toward coordinated care organizations. Regional authorities with true global budgets and the combined data systems of insurers willing to invest in those regions could manage the information flow to providers and avoid the restrictions imposed by network contracting in managed care. We remain in silos and yet somehow think we are making progress. Terry Hammond