October 26

Cost and Consequence: drug "cocktails" deplete Medicaid_Globe

Cost and Consequence: drug “cocktails” deplete Medicaid_Globe

Tue, 24 Jun 2003

The escalating cost of healthcare is in large measure due tothe spiraling expenditure on drugs–many of which are misprescribed.The Boston Globe reports about one Medicaid patient who is prescribed18 medications at a cost of roughly $16,000 a year–“all at the expense of the financially struggling MassachusettsMedicaid program.”

The woman (who was alcoholic) is a pharmaceutical company’sdream consumer. Thanks to psychiatrists’ poly-pharmacy prescribingpractices she is taking multiple costly drugs of the same class.Such prescribing practices are more likely to generate drug-inducednew pathologies than to cure the condition for which they are prescribed.What some would call malpractice, is an incredibly lucrative marketingstrategy.

According to Massachusetts Medicaid, the 10 most prescribed drugs underthe Medicaid program are:

1. Zyprexa (antipsychotic) costs Massachusetts taxpayers $4.2 million,
2. Protonix (heartburn) costs $3.6 million
3. Risperdal (antipsychotic) costs $3.1 million
4. Lipitor (anti-cholesterol) costs $2.8 million
5. Seroquel (antipsychotic) costs $2.8 million
6. Neurontin (neuropathic pain…) $2 mill
7. Depakote (antidepressant) $1.7 million
8. OxyContin (narcotic) $1.6 million
9. Zoloft (antidepressant)$1.5 million
10. Paxil (antidepressant) $1.2 million

7 of the 10 drugs are expensive psychiatric drugs that are eating upthe Medicaid budget. The Boston Globe reports that about 40,000 patientsin the Massachusetts Medicaid program take eight or more medications.”Thousands of other patients take five or more psychiatric drugs,more than one newer antidepressant, or more than one newer antipsychotic.”

Furthermore, “For patients on eight or more drugs or five or morepsychiatric drugs, Medicaid officials will try toeducate doctors about why this could be a health problem.”

One must wonder about the professional competence of State licensedpsychiatrists who prescribe powerful, mind altering drugs, yetare ignorant about these drugs’ potential to cause patients harm.

Cost and consequence
Medicaid aims to curb ‘poly-pharmacy’ approach, but drug limits mayundermine patients’ health

By Liz Kowalczyk, Globe Staff, 6/22/2003

Seven years ago, Cheryl Desio was homeless and addicted to alcohol,sometimes sleeping on a gym mat in a friend’s basement, other times stayingbriefly in a shelter or with one of her children. One night, drunk andangry, she remembers showing up at Massachusetts General Hospital lookingfor psychiatric help and began a long climb up, to treatment programs at theSalvation Army in Brockton, Father Bill’s Place in Quincy, Boston’s LemuelShattuck Hospital, and the Edwina Martin House in Brockton. Finally shemoved into a low-income apartment in Dorchester, which she shares with aroommate, and onto Medicaid, the government’s health insurance program forthe poor.

”Cheryl is a real survivor,” said Dr. Michael Folino, her primary carephysician. ”It’s amazing to me she’s still living and doing well.”

Desio, 50, is amazed, too, especially at her children’s generosity andrespect since she became sober. One daughter pays her monthly phone billwhile a son bought her reading glasses. ”We’re so proud of her,” said herdaughter Stacy Konopka, 27. ”Growing up with her drinking was really hard.Her life was spiraling down. This year she called me on Mother’s Day,because I have a new daughter. To have her do that, was amazing.”

But keeping her fragile life and health together is not easy. Desio takes 18medications, for diabetes, depression, anxiety, pain, and emphysema, all atthe expense of the financially struggling Massachusetts Medicaid program.The cost for her medicines alone: roughly $16,000 a year.

On July 1, Medicaid officials will start reviewing Desio and other”poly-pharmacy” patients — those using many medications or severalmedications in the same class — for its newest cost-cutting initiativeaimed at controlling the state’s skyrocketing prescription drug costs.Medicaid officials believe that pushing doctors to reduce the number ofmedications individuals take will not only save the state as much as $20million annually but will reduce dangerous side effects and druginteractions for patients.

Many doctors fear the initiative will have unintended consequences forseriously ill Medicaid recipients like Desio, whose complex conditions oftenrequire an equally complicated drug cocktail. ”The question is what happenswhen you take one brick out of the foundation?” said Folino, medicaldirector of Harbor Health Services Inc., a group of three community healthcenters in Boston.

Desio’s doctors don’t know whether Medicaid officials will push them toreduce or change her medications, or whether the reviewers who monitor drugsfor the agency will find them all medically necessary. But Desio is anxious.”I am scared of this,” she said. ”I’m doing the best I can to keep myselfwell.”

Medicaid officials have been struggling to control the program’s growing$1.1 billion pharmacy budget by switching many patients from expensive brandname drugs to cheaper generics. When generics don’t exist, most patients nowcan take only the cheapest brand name drug for a particular condition.

When Desio tried to renew her prescriptions for the antidepressant Lexaproand the migraine medication Maxalt two weeks ago, her pharmacist saidMedicaid would no longer pay for these expensive drugs — unless her doctorsget special permission.

But these measures, Medicaid officials say, have done nothing to address apressing cost problem that also may be hurting patients’ health. About40,000 patients take eight or more medications. Thousands of other patientstake five or more psychiatric drugs, more than one newer antidepressant, ormore than one newer antipsychotic. Officials don’t know precisely how muchthese members’ medicines cost the program, which insures 950,000 poor anddisabled residents, but still think some of it is wasteful spending.

Starting July 1, Medicaid officials will use a computer program to identifythese patients and call their physicians to ask them to reduce theirmedications. Patients will not be allowed to take more than one newerantidepressant or more than one newer antipsychotic — unless a doctorproves with medical records that the combination works better for thepatient than a single drug.

For patients on eight or more drugs or five or more psychiatric drugs,Medicaid officials will try to educate doctors about why this could be ahealth problem. Massachusetts is one of the first states to targetpoly-pharmacy, said Mike Fitzpatrick, director of policy research for theNational Alliance for the Mentally Ill, a nonprofit advocacy group basednear Washington, D.C. But he said many states now are following suit. Texasplans to limit patients to four brand name drugs per month, and Eli Lilly &Co., maker of a number of psychiatric drugs, gave Missouri several hundredthousand dollars in part to educate doctors who are prescribing patients toomany psychiatric drugs.

”There is increasing evidence that members are getting many drugs thataren’t appropriate or are excessive,” said Douglas Brown, Massachusettsacting Medicaid director. ”If we focus on the relatively small number ofpeople on high numbers of drugs, we can improve their health care and savemoney.”

But Dr. George Sigel, Desio’s psychiatrist, objects to governmentinterference in his medical judgments, and worries these initiatives willshake patients’ confidence in their doctors. ”They won’t know if the doctoris thinking about what’s best for them, or about how time-consuming it’sgoing to be for him to get permission from Medicaid,” he said. The state’s”prior approval” forms are two-pages long and require a detaileddescription of the patient’s medical history. ”There’s no way deleting anyof Cheryl’s medications on the basis of cost is going to be good for her,”he said.

Other physicians are not so sure. Medicaid officials — and some doctors –say that for various reasons, including health insurers’ reluctance to payfor long hospital stays and intensive outpatient psychotherapy since theadvent of managed care, poly-prescribing or poly-pharmacy has gotten out ofhand. Dr. Marie Hobart, a Worcester psychiatrist who serves on the Medicaidcommittee that developed the new poly-pharmacy rules, said the agencyprimarily wants to cut costs but deserves credit for taking a clinicalapproach. The committee reviewed studies on poly-prescribing and interviewedexperts.

Widespread poly-pharmacy came about, she said, partly because doctors inclinics are struggling to see huge numbers of complicated patients.”Sometimes these multiple medicines have been arrived at in a painstakingway,” she said. ”Other times we have patients who are very difficult totreat and very little time to spend with them, and it becomes more difficultto make changes in their medicines.”

Dr. James Ellison, a psychiatrist on the committee and president of theMassachusetts Psychiatric Society, said patients tapering off one medicationand starting another sometimes feel better and believe it’s the combinationrather than the new drug taking effect. And sometimes, he said, doctorsresort to poly-pharmacy in desperation on difficult patients for whom nodrug seems to work. Out of 200 patients he’s treating for depression, oneman takes two newer antidepressants known as Selective Serotonin Re-uptakeInhibitors — even though no proof exists for this combination.

”I don’t think that’s why the patient is doing well, but he stronglybelieves this is useful,” Ellison said. ”My worry is that we’re exposinghim to increased side effects, and for society, we’re drawing resources awayfrom other problems.”

Folino, Desio’s doctor, said he is not a fan of poly-pharmacy but that itwill be difficult to comply with the state’s directive in complicated caseslike hers. Desio has hepatitis C, diabetes, and chronic obstructivepulmonary disease from years of smoking and not taking care of herself. Shealso has cervical stenosis, a narrowing of the spinal canal that pinches thenerves, and migraines that cause her severe pain.

Desio, who has huge light blue eyes and a worn look, takes medicines fourtimes daily. The regimen is so complicated a nurse has written it on a bigsheet of paper. A good day is when she can walk around the Harborpointhousing development in Dorchester or sit on a bench near the ocean. Lessoften recently is a bad day — or two or three together — when she can’tget out of bed.

Folino said Desio’s drugs interact in such a way that she needs more thanone medication for each problem. For example, she requires a steroid,Advair, to help her breathe. But that elevates her blood sugar, so Folinohas had to put her on three diabetes medications. Steroids also candestabilize her anxiety and depression; she’s on four medications to controlthose conditions. But she has to be careful about which antidepressants shetakes because they can cause weight gain, and in turn aggravate herdiabetes.

Even so, Desio is having symptoms Folino said could be the result ofmultiple drug interactions. Her roommate has called an ambulance many timesbecause Desio has gotten dizzy, fallen, and been unable to stand up. Folinoreferred her to yet another doctor, a neurologist.

”Obviously it’s a delicate balance,” Folino said. ”This could have to do with poly-pharmacy. But on the other hand, with the combination she’s on she’s functioning as well as she ever has.”

This story ran on page E1 of the Boston Globe on 6/22/2003.© Copyright 2003 Globe Newspaper Company.

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