AACP Newsletter, Volume 14,
Number 1, Winter 2000
Atypical Antipsychotics
Bazelon has the survey results at http://www.bazelon.org/issues/medicaid/formulary.htm.
The good news from the study is that there was little evidence for barriers to access to these "expensive" medications at the formulary level. This finding would be expected since top managers in the HCFA system have publicly acknowledged their appreciation for the relative superiority of these agents over the older "typical" antipsychotics. The bad news in my opinion, is that many areas of the country are experiencing a disconnect between formulary policy and actual practice.
In my opinion, the contents of state or regional formularies are hardly an indicator for the availability of these medications at the prescription level. As a national educator and consultant, I am observing many examples of efforts to restrict access to these new medications within systems of care. Typically, clinicians and administrators are keenly (and painfully) aware of acquisition costs for these medications, but are unaware of their potential "offset" effects, i.e., their ability to reduce expensive utilization of services, especially hospitalization. Armed only with this short term knowledge, they/we set caps on numbers of prescriptions per month, impose co-pays, request prior authorization, implement "fail-first" policy, etc. In some cases, efforts to restrict access to these medications are more subtle and covert. The most malignant example of this covert process is where the clinician cannot prescribe simply because the patient does not have the funds to pay. We as prescribers are left to "ration" these medications without any guidelines or data to support clinical decision-making at the patient level. When this happens, we end up making clinical decisions based on our patient's personal means rather than on his/her clinical condition. It is painful to say it, but I feel that unless we take an advocacy position on behalf of our patients, we become accomplices in a de facto rationing process that may not be fair or clinically sound. As it currently stands, less than 50% of persons with schizophrenia receive atypical antipsychotic agents, and science is already telling us that there is increased utilization of expensive services and increased morbidity when the older less expensive drugs are prescribed.
I am interested in advocating for patient access to the new generation of atypical antipsychotic agents. My opinion that these medications should have replaced the older ones by now is based on many published studies, but the main basis comes from early studies that are showing how these medication diminish the risk of TD relative to older antipsychotics. To advocate, I have created a survey at my website - http://www.glazmedsol.com. This is a national survey of practitioners, patients, families and administrators regarding the availability of the new antipsychotic agents to patients. I am conducting the survey because there are no good data to tell us what is really going on in this area. I want to use the data to advocate for the SMI population in the US via my lectures, writing, practice and other strategic efforts. My efforts are my own and are not funded by industry. I would appreciate it if you, my fellow members of the American Association of Community Psychiatrists, would take three minutes to log on to my website, and click on the invitation to take the survey at the bottom of the page. You may answer anonymously if you wish, and in the "MedAccess" section of this website, you will also be able to read background material and scientific references that support the statements that I have made about the medications in this article.
Thank you for your help. I hope to write up what I find and report it in a future edition of this newsletter.
William M. Glazer, MD
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