Glenn Liebman, CEO
Mental Health Association in New York State, Inc.

Testimony to

JOINT BUDGET HEARINGS OF THE NEW YORK STATE
SENATE AND ASSEMBLY ON HEALTH

2005

Thank you very much, Chairmen Johnson and Farrell, Senator Hannon and Assemblymember Gottfried, for providing us with the opportunity to provide testimony regarding Governor Pataki’s 2005-06 Executive budget proposal. We appreciate the opportunity to discuss with you the issues of importance to individuals living with mental health needs throughout this state.

Medicaid provides a valuable source of treatment for individuals living with mental illness. As the ‘insurance of last resort,’ many individuals living with a mental illness cannot access treatment in any other manner. Further, because of the economic and social impact of chronic mental health conditions, the long-term treatments necessary are often times not available through any resource except Medicaid.

It is for this reason that the Mental Health Association in New York State (MHANYS) is deeply concerned about many of the Governor’s proposals with regard to the Medicaid system in this year’s budget. As part of the Medicaid Matters Coalition, we wholeheartedly support the positions outlined by this organization and it’s member organizations as they pertain to Family Health Plus, the elimination of “optional” services under Medicaid, increased co-payments for prescription drugs in Medicaid, mandatory spend-down for spouses and family members of disabled in order to qualify for Medicaid, and public health cuts and restrictions to New York’s Early Intervention program. We will leave in-depth discussion of many of these issues to other members of Medicaid Matters and focus our attention on the issues that pertain to individuals living with mental health needs.

Perhaps of greatest concern to us are the proposed changes to the Family Health Plus program. This program provides access to comprehensive health coverage for eligible low-income adults who do not have insurance though their employers, yet have incomes that do not qualify them for other publicly financed health programs. Such changes would include “making the benefit package consistent with that offered through Healthy New York.” As advocates who have been working toward ending disparate insurance coverage for mental health services as compared to other health services under private health insurance through passage of Timothy’s Law, the proposed elimination of coverage for mental health services under Family Health Plus represents a move away from comprehensive health coverage. The hundreds of members of the Timothy’s Law Campaign, as well as the O’Clair family, see this as a major step backwards in our efforts to end insurance discrimination against individuals living with mental health needs.

The proposed elimination of “optional” services, such as psychological, dental and podiatric services, represents yet another significant step backward in the effort to ensure comprehensive health services to all New Yorkers. The elimination of psychological services, in particular, under Medicaid would result in a major gap in the system of care for New Yorkers who need these services, and must be restored.

As in previous years, MHANYS continues to oppose efforts to implement a Preferred Drug Program (PDP) within Medicaid. MHANYS has stood up repeatedly, with over 20 other organizations, to oppose the implementation of a Preferred Drug List (PDL), supplemental rebates, and prior authorization (PA). We are appreciative that the Governor has exempted atypical anti-psychotics and anti-depressants from the provisions of the PDP. This is an important recognition of the needs of individuals living with psychiatric disabilities. Unfortunately, it does not go far enough, in that many of the medications for bi-polar disorder, anxiety disorders, and other crippling mental illnesses and all of the medications prescribed to deal with the crippling side effects of many mental health drugs would still be subject to the PDL. In addition, when considering the fact that more than 50% of individuals with a serious mental illness have a co-occurring serious physical illness as well, even with the exemptions listed in the Governor’s proposal, a PDP would create a greater strain on this vulnerable population.

Primarily, the mantra of the consumer movement has been, “Nothing about us without us.” The creation of this particular Pharmacy and Therapeutics (P&T) Committee stands in direct contrast to consumer empowerment. The proposed legislation decreases the amount of consumer representation on the P&T Committee from 3, as proposed in previous years, to 1. In addition to this, there is no stipulation that any of the P&T Committee members have specialized knowledge about mental health. As an area of medicine so distinct from other fields, at the least, there should be psychiatric representation on the Committee.

Under the proposed PDP, the P&T Committee has sole discretion over the creation of Theraupeutic Classes. We are very concerned that the P&T Committee’s creation of a therapeutic class would define exempted classes narrowly and limit the number of medications included under the proposal, thus resulting in more medications that would be subject to a PDL. Such a determination should be made solely on the best clinical judgment of medical professionals, independent of cost considerations.

Also under the proposed legislation, medical professionals would be granted the final say as to whether or not a patient gets a medication, but only after a PA request is approved. Given current practice and low rates, we are concerned that very few doctors seeing Medicaid patients would spend the time to seek PA. Furthermore, the complete lack of an appeals process for those who have a PA denied will have a devastating effect on many individuals living with mental health needs.

This prospect gives us even greater concern when the criteria for PA are considered. In that the PDP does not exempt mental health drugs other than atypical anti-psychotics and anti-depressants, medications used to manage the devastating side effects of some mental health drugs, and medications used to treat the co-occurring physical health needs of individuals with mental health needs, the PDP and the PA process would still greatly impact individuals with mental health needs. Trying to strike a balanced prescription formula to treat all of the mental and physical health needs of an individual is a delicate and time consuming process that will only be further exacerbated by restrictions on the drugs accessible.

The Governor’s proposal to create a Clinical Drug Review Program (CDRP) would effectively create a separate PDP within the PDP, allowing the language exempting certain medications to be sidestepped by placing “similarly effectively alternatives” in the CDRP, which contains no such exemptions. Further, the CDRP would effectively permit restriction of access to medications based primarily on cost, not clinical effectiveness. The Governor’s proposal also does not stipulate what the prior authorization process will entail for those drugs placed in the CDRP. The CDRP would restrict access to medications not clinically indicated for a particular disease or population, this would effectively remove the flexibility physicians currently exercise to prescribe medications that would be effective. For example, if a CDRP were to be enacted, the new pharmaceutical technologies that have proven useful in areas other than where there were intended would be greatly restricted. This would have a tremendous impact on the ability of physicians to prescribe anti-depressants and other mental health drugs for children.

Only by exempting the person with the chronic condition, and not the pills they are taking, can we begin to address the consumer protections that would be necessary for even a basic bill. There is absolutely no clinical evidence indicating that a PDP would improve the quality of care for Medicaid recipients. With that in mind, we continue to argue that the only good PDP is no PDP.

There are other alternatives which would save money while preserving access. We would look forward to working with you in investigating these alternatives. One such alternative is the concept of poly-pharmacy – identifying and reviewing individuals who are filling Medicaid prescriptions far in excess of the average for those with similar diagnoses. This is a concept that has been successfully enacted in many states, allowing these states to realize millions in savings, promote the best clinical science, and identify and reduce fraud. While poly-pharmacy efforts are most often targeted at mental health, experience dictates that there are many people receiving multiple medications for physical health ailments – from chronic pain to heart disease and blood pressure. Addressing the issue of over-prescription of medication may indeed lead to better health care and lower costs.

Once again, thank you for the opportunity to provide you with our thoughts in regard to the Governor’s budget proposal. In sum, though we are appreciative of the proposed carve out of mental health drugs in the PDP, we have great concerns with the overall PDP, as well as other proposed Medicaid cuts including the elimination of mental health coverage from Family Health Plus. We thank you very much for providing us with the opportunity to share our testimony regarding the Governor’s budget proposal.