Open Medication Access Advocates Considering Prescriber Prevails, Goldcard Proposals

NYAPRS Note: Governor Cuomo proposes to repeal provisions won in last year’s budget that would allow prescribers to get atypical (‘newer’) anti-psychotic medications they and their patients believe is best, even if those drugs are not on the preferred drug lists (formularies) of the 18 Medicaid managed health plans that oversee the pharmacy program.

The current ‘prescriber prevails’ program that was rolled out in January helps ensure that people get those drugs, but only after the requests pass a layer of health plan approval (prior authorization).

The Administration is alternatively proposing a ‘goldcarding program’ that is being developed with advocates’ input and that would give eligible prescribers full prescriber prevails precedence over plan prior authorization requirements.

The goldcard program could potentially be extended to psychiatrists who are in good standing with licensing agencies, are Board Certified or eligible, disclose financial relationships with pharmaceutical manufacturers and are in compliance with approved prescribing standards. Goldcard privileges might also be granted to non-psychiatrist prescribers who meet the above standards and who have collaborative care consultation agreements with psychiatrists.

NYAPRS will continue to advocate for the proposal that provides the most assurances that people get the right medications they want and need without any delay, especially those who get their medications through the plans, which include Affinity, Amida Care, CDPHP, EmblemHealth, Excellus, Fidelis, HealthFirst, Health Plus/Amerigroup, Health Now, Hudson Health Plan, Independent Health, MetroPlus, MVP, Neighborhood Health Providers, Total Care, United Health Care, Univera, VNSNY CHOICE and WellCare.

A key factor will lie in whether the state can fully finalize and fund the goldcard proposal and present it to state legislators before the April 1 state budget deadline.

Rockland Health Providers Protest Cuomo Plan to Force Mentally Ill to Use Generic Drugs

By Sarah Armaghan Newsday February 22, 2013

Rockland County mental health professionals say they fear for their psychiatric patients' safety as Gov. Andrew M. Cuomo looks to cut more than $11 million in Medicaid spending by replacing brand-name prescriptions for the mentally ill with generic drugs.

Cuomo's elimination of "prescriber prevails" - a provision that was restored in last year's state budget - would affect people who take certain anti-psychotic drugs for conditions that include schizophrenia and bipolar disorder. The provision allows psychiatric patients to get brand-name drugs rather than less expensive generics.

If it is not restored, Medicaid would be able to mandate generic drugs and save $9.38 million annually, as well as an additional $1.38 million for all other drug classes in the state's $54 billion Medicaid budget, according to state Sen. David Carlucci (D-Rockland/Orange).

"Drug interactions are very important, and maintaining that balance is something that a physician works hard to monitor," said Dr. Joe Zweig, a program director at Jawonio, a New City organization that deals with children and adults with disabilities and special needs.

Carlucci, chairman of the State Senate's Mental Health Committee, staged a news conference Thursday afternoon at the Mental Health Association of Rockland County in Valley Cottage, where a number of mental health professionals and supporters gathered to decry Cuomo's decision.

"We want to make sure that prescriber prevails stays in the budget [and] that insurance companies don't get in the way of a doctor and their patient," Carlucci said.

Stephanie Madison, president and CEO of Mental Health Association of Rockland County, said it's physicians, not insurance companies, that have the expertise needed to treat patients.

"If insurance companies and managed care companies are making decisions on behalf of their clients, we know that ultimately, care will be compromised and [patients] will not be able to have the recovery they deserve," Madison said.

Carlucci argued that as some medicine is changed under the new provisions, it could end up costing the taxpayer more in emergency care and further treatment.

"I think this is ultimately about saving money. This is an issue where if we do it wrong, we're going to pay more in the end," Carlucci said. By reversing [it] we'll be paying more, sending people to emergency rooms and worsening their care."

Levi Riddick, who has coordinated care for the mentally ill for the past eight years, said the cuts will "erode the doctor/patient relationship."

"When changing medications, the slightest deviation from what a person is used to could send them into a tailspin," Riddick said. "We tell our patients to pick up the phone and talk to their doctor and let them know what's going on. They feel assured. Calling an insurance company and being told, 'Please hold,' that's not going to do it for us."

Cuomo's original $136 billion budget proposal was submitted last month. The state has until March 31 to approve it.

A Cuomo spokesman did not immediately respond to a request for comment.


Carlucci, Mental Health Advocates Seek Reinstatement of Program Protecting Doctor's Rights to Prescribe

Without the program, insurance companies can decide what medication patients receive.

ByAdam Littman Pearl River Patch February 22, 2013

Laurie Lindell suffered lingering nerve damage in her right hand when she was hit by a car in 2001.
Lindell’s doctor often talked to her about leaving her job as an office manager in the manufacturing field, but Lindell didn’t want to stop working.

“I like to work, I liked my job,” she said. “But the pain didn’t really go away and just got worse. Some nights I’d go home and cry because of how much pain I was in.”

Her doctor also prescribed various medications, which helped with the pain, Lindell said. However, her insurance company didn’t think she needed the medication, or any at all.

“They would tell me it’s all in my head, that I didn’t need it,” she said.

Lindell knew how she felt, though, and knew the pain only got worse over the years since the accident. She took disability leave in October 2011 because she couldn’t keep performing her job with her injury. The doctor and Lindell continued to fight the insurance company so she could keep receiving the medication.

Her doctor also put her in touch with theNew York Pain Society, from which she discovered theU.S. Pain Foundation. Lindell, who lives in Long Island but was raised in Bardonia and graduated from Clarkstown South, is now the vice president of development for the U.S. Pain Foundation, advocating for others going through similar issues with insurance companies.

On Thursday, Lindell and a group of advocates joined State Sen. David Carlucci at the Mental Health Association of Rockland County in Valley Cottage to urge Gov. Andrew Cuomo to reinstate prescriber prevails for atypical antipsychotics in the 2013-2014 state budget. Prescriber prevails ensures that only doctors and physicians have the authority to prescribe medication.

“We want to make sure that prescriber prevails stays in the budget, that we fund it, that we make sure that insurance companies don’t get in the way of a doctor and their patient,” Carlucci said. “Right now, what we see is that these insurance companies or manage care providers, what they’re doing is really sitting back and having these prescription benefit managers - basically, what you could call almost like actuaries - sitting back in an office and deciding which medications are appropriate for a patient that they’ve never seen.”

Carlucci and Lindell gathered Thursday with President/CEO, Mental Health Association of Rockland County Stephanie Madison, Jawonio Division Director of Behavioral Health Services Sharon Kuriger, Jawonio Director of Personal Recovery Oriented Services Dr. Joe Zweig and Rockland Independent Living Center Senior Peer Specialist Levi Riddick.

Riddick said many patients he deals with are most comfortable living with a certain routine, and even the slightest deviation could “send them into a tailspin.” Because of that, he doesn’t think it’s a good idea to possibly switch medication so swiftly for patients. Also, many of them develop relationships with their physicians and call them for help. He said it could be dangerous for the patients to seek out help only to be put on hold by an insurance company or not get to talk to a person.

Carlucci said the program comes with an appeals process if the new medication prescribed by the insurance company isn’t working, but that could take weeks, which gives plenty of time for the patients to destabilize. He also said that with the recent debate about gun safety, the phrase “mental health” has been thrown around quite a bit, but something like taking away prescriber prevails shows a lack of understanding about mental health.

“I’m beginning to think that a lot of these pundits don’t even know what mental health means, because they say we need more mental health services, better access, and then you see policies like this come out, where we’re saying yes, someone might not anti-psychotic medication and we’re going to deny them that medication,” he said. “So this is very troubling, and I think it’s important that we, as leaders in New York state, that we put our money where our mouth is and we actually deliver on these services.”

He also said that changing medication on the patients could result in an increase in the number of people needing to go to the hospital, so any costs one might think would come from not reinstating the program wouldn’t really help.

“This is, ultimately, about saving money because this is an issue where if we do it wrong, we’re going to pay more in the end,” Carlucci said. “And if we’re looking at saving Medicaid dollars, reversing prescriber prevails is not the way to go. Reversing prescribe prevails, all we’re going to do is increase the bottom line for insurance companies and those stockholders and decrease the bottom line for us, the taxpayers. We’re going to be paying more in Medicaid by sending people to emergency rooms and worsening their care.”

Lindell said that not only could taking away prescribed prevails result in more trips to the emergency room for patients, but it makes them feel like a number rather than a person. While going through her issues with the insurance company, Lindell said she felt extremely demoralized.

“You feel like nothing,” she said. “You feel like you don’t exist. You really have to have a good doctor and someone willing to fight with you. Without the right support system, you’re in trouble.”

Zweig noted that people with mental health problems typically live shorter than most, and Carlucci said treating people with incorrect medication could further harm them.

“Unfortunately people suffering from mental health issues have a shorter life expectancy, and not because of their condition but because of the drugs that they’ve been taking, in many cases,” Carlucci said. “Switching someone from a drug that the doctor knows works to another drug is just really a prescription for failure.”