Medicaid: Too Many Drugs are Mis-Prescribed
The escalating cost of healthcare is in large measure due to
the spiraling expenditure on drugs--many of which are mis-prescribed. The
Boston Globe reports about one Medicaid patient who is prescribed 18
medications at a cost of roughly $16,000 a year-- "all at the expense of the
financially struggling Massachusetts Medicaid program."
The woman (who was alcoholic) is a pharmaceutical company's dream consumer.
Thanks to psychiatrists' poly-pharmacy prescribing practices she is taking
multiple costly drugs of the same class. Such prescribing practices are more
likely to generate drug-induced new pathologies than to cure the condition for
which they are prescribed. What some would call malpractice, is an incredibly
lucrative marketing strategy.
According to Massachusetts Medicaid, the 10 most prescribed drugs under the
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 up the
Medicaid budget. The Boston Globe reports that about 40,000 patients in 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 more psychiatric
drugs, Medicaid officials will try to educate doctors about why this could be
a health problem."
One must wonder about the professional competence of State licensed
psychiatrists who prescribe powerful, mind altering drugs, yet are ignorant
about these drugs' potential to cause patients harm.
- ALLIANCE FOR HUMAN RESEARCH PROTECTION (AHRP)
http://www.ahrp.org
Contact: Vera Hassner Sharav
Tel: 212-595-8974
e-mail:
veracare@ahrp.org
~~~~~~~~~~~~~~~~~~~~~~
http://www.boston.com/dailyglobe2/173/business/Cost_and_consequence+.shtml
Cost and consequence
Medicaid aims to curb 'poly-pharmacy' approach, but drug limits may
undermine 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 staying briefly in a
shelter or with one of her children. One night, drunk and angry, she remembers
showing up at Massachusetts General Hospital looking for psychiatric help and
began a long climb up, to treatment programs at the Salvation Army in
Brockton, Father Bill's Place in Quincy, Boston's Lemuel Shattuck Hospital,
and the Edwina Martin House in Brockton. Finally she moved into a low-income
apartment in Dorchester, which she shares with a roommate, and onto Medicaid,
the government's health insurance program for the poor.
''Cheryl is a real survivor,'' said Dr. Michael Folino, her primary care
physician. ''It's amazing to me she's still living and doing well.''
Desio, 50, is amazed, too, especially at her children's generosity and respect
since she became sober. One daughter pays her monthly phone bill while a son
bought her reading glasses. ''We're so proud of her,'' said her daughter 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 18
medications, for diabetes, depression, anxiety, pain, and emphysema, all at
the 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 several
medications in the same class -- for its newest cost-cutting initiative aimed
at controlling the state's skyrocketing prescription drug costs. Medicaid
officials believe that pushing doctors to reduce the number of medications
individuals take will not only save the state as much as $20 million annually
but will reduce dangerous side effects and drug interactions for patients.
Many doctors fear the initiative will have unintended consequences for
seriously ill Medicaid recipients like Desio, whose complex conditions often
require an equally complicated drug cocktail. ''The question is what happens
when you take one brick out of the foundation?'' said Folino, medical director
of Harbor Health Services Inc., a group of three community health centers in
Boston.
Desio's doctors don't know whether Medicaid officials will push them to reduce
or change her medications, or whether the reviewers who monitor drugs for 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 myself well.''
Medicaid officials have been struggling to control the program's growing $1.1
billion pharmacy budget by switching many patients from expensive brand name
drugs to cheaper generics. When generics don't exist, most patients now can
take only the cheapest brand name drug for a particular condition.
When Desio tried to renew her prescriptions for the antidepressant Lexapro and
the migraine medication Maxalt two weeks ago, her pharmacist said Medicaid
would no longer pay for these expensive drugs -- unless her doctors get
special permission.
But these measures, Medicaid officials say, have done nothing to address a
pressing cost problem that also may be hurting patients' health. About 40,000
patients 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. Officials don't know precisely how much these
members' medicines cost the program, which insures 950,000 poor and disabled
residents, but still think some of it is wasteful spending.
Starting July 1, Medicaid officials will use a computer program to identify
these patients and call their physicians to ask them to reduce their
medications. Patients will not be allowed to take more than one newer
antidepressant or more than one newer antipsychotic -- unless a doctor proves
with medical records that the combination works better for the patient 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 a
health problem. Massachusetts is one of the first states to target
poly-pharmacy, said Mike Fitzpatrick, director of policy research for the
National Alliance for the Mentally Ill, a nonprofit advocacy group based near
Washington, D.C. But he said many states now are following suit. Texas plans
to limit patients to four brand name drugs per month, and Eli Lilly & Co.,
maker of a number of psychiatric drugs, gave Missouri several hundred thousand
dollars in part to educate doctors who are prescribing patients too many
psychiatric drugs.
''There is increasing evidence that members are getting many drugs that aren't
appropriate or are excessive,'' said Douglas Brown, Massachusetts acting
Medicaid director. ''If we focus on the relatively small number of people on
high numbers of drugs, we can improve their health care and save money.''
But Dr. George Sigel, Desio's psychiatrist, objects to government interference
in his medical judgments, and worries these initiatives will shake patients'
confidence in their doctors. ''They won't know if the doctor is thinking about
what's best for them, or about how time-consuming it's going to be for him to
get permission from Medicaid,'' he said. The state's ''prior approval'' forms
are two-pages long and require a detailed description of the patient's medical
history. ''There's no way deleting any of 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 pay for
long hospital stays and intensive outpatient psychotherapy since the advent of
managed care, poly-prescribing or poly-pharmacy has gotten out of hand. Dr.
Marie Hobart, a Worcester psychiatrist who serves on the Medicaid committee
that developed the new poly-pharmacy rules, said the agency primarily wants to
cut costs but deserves credit for taking a clinical approach. The committee
reviewed studies on poly-prescribing and interviewed experts.
Widespread poly-pharmacy came about, she said, partly because doctors in
clinics are struggling to see huge numbers of complicated patients.
''Sometimes these multiple medicines have been arrived at in a painstaking
way,'' she said. ''Other times we have patients who are very difficult to
treat and very little time to spend with them, and it becomes more difficult
to make changes in their medicines.''
Dr. James Ellison, a psychiatrist on the committee and president of the
Massachusetts Psychiatric Society, said patients tapering off one medication
and starting another sometimes feel better and believe it's the combination
rather than the new drug taking effect. And sometimes, he said, doctors resort
to poly-pharmacy in desperation on difficult patients for whom no drug seems
to work. Out of 200 patients he's treating for depression, one man takes two
newer antidepressants known as Selective Serotonin Re-uptake Inhibitors --
even though no proof exists for this combination.
''I don't think that's why the patient is doing well, but he strongly believes
this is useful,'' Ellison said. ''My worry is that we're exposing him to
increased side effects, and for society, we're drawing resources away from
other problems.''
Folino, Desio's doctor, said he is not a fan of poly-pharmacy but that it will
be difficult to comply with the state's directive in complicated cases like
hers. Desio has hepatitis C, diabetes, and chronic obstructive pulmonary
disease from years of smoking and not taking care of herself. She also has
cervical stenosis, a narrowing of the spinal canal that pinches the nerves,
and migraines that cause her severe pain.
Desio, who has huge light blue eyes and a worn look, takes medicines four
times daily. The regimen is so complicated a nurse has written it on a big
sheet of paper. A good day is when she can walk around the Harborpoint housing
development in Dorchester or sit on a bench near the ocean. Less often
recently is a bad day -- or two or three together -- when she can't get out of
bed.
Folino said Desio's drugs interact in such a way that she needs more than one
medication for each problem. For example, she requires a steroid, Advair, to
help her breathe. But that elevates her blood sugar, so Folino has had to put
her on three diabetes medications. Steroids also can destabilize her anxiety
and depression; she's on four medications to control those conditions. But she
has to be careful about which antidepressants she takes because they can cause
weight gain, and in turn aggravate her diabetes.
Even so, Desio is having symptoms Folino said could be the result of multiple
drug interactions. Her roommate has called an ambulance many times because
Desio has gotten dizzy, fallen, and been unable to stand up. Folino referred
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.''
Liz Kowalczyk can be reached at kowalczyk@globe.com.
This story ran on page E1 of the Boston Globe on 6/22/2003. © Copyright 2003
Globe Newspaper Company.
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