Oregon continues to wrestle with prescribing practices for psychotropics

The Bend Bulletin, April 30, 2015

pillsBack to the drawing board for mental health advocates in Oregon.

State Medicaid programs have struggled for years to tackle the high and often inappropriate prescribing of psychotropic — mental health — drugs to clients, who tend to experience higher rates of mental health conditions than the general population.

Oregon is no exception. A number of proposals have been floated to solve the problem of psychotropic drugs being overprescribed to people who rely on the Oregon Health Plan, the state’s version of Medicaid. Advocates are specifically concerned about the prescribing to children, which can have unintended consequences on developing brains.

Nearly 19 percent of children in the Oregon Child Welfare Program received at least one psychotropic medication in January 2013, according to Oregon State University’s College of Pharmacy. Of those, nearly half received at least one antipsychotic.

The most recent attempt to stem the tide of drugs died in the Legislature last week, but it appears to have moved the debate forward.

A House bill would have given the state’s 16 coordinated care organizations, the groups that manage care for OHP clients in their region, control over the prescribing of psychotropic medications. Although CCOs already dispense most prescription drugs for their members, psychotropic drugs are carved out at the state level.

The idea behind the new measure was that managing the care at the local level would ensure patient safety by improving coordination between providers, because the CCO would oversee payments for all of patients’ medications.

Currently, CCOs don’t have access to complete, real-time information about their members, so a physician could prescribe a pain medication without knowing whether that patient had received a prescription from a mental health provider for a psychotropic drug that might not mix well with it, Julie Mohr Peterson, the state’s OHP director, said at a Feb. 11 hearing on the bill.

“We believe that it’s good clinical quality of care to be able to include all of those things under the same entity,” she said.

But the measure didn’t stand much of a chance. It drew significant opposition from all corners of the issue. Mental health advocates and families said they feared it would lead to the severely mentally ill being denied essential medications or their regimens altered in favor of cheaper treatments.

Even a delay of a few days so that the CCO can sign off on a prescription could spur a crisis, said Chris Bouneff, the executive director of the National Alliance on Mental Illness’ Oregon chapter, which opposed the measure.

“What the pharmacist tells you is, ‘I can’t fill this, you have to come back later,’” he said, “and what you, a person in some type of crisis or distress hears is, ‘I can’t get my medications.’ And the odds increase dramatically that you are going to essentially leave the treatment system. You’re not coming back until things get worse for you.”

Most of the CCOs themselves opposed the bill, arguing they would rather work together along with stakeholders to craft a more thoughtful way to manage medications.

Bouneff said he agrees CCOs should manage psychotropic medications, but any measure that allows that to happen must have significant protection to ensure clients can keep their medications.

Once the current legislative session wraps up, CCOs and behavioral health leaders from across the state will meet regularly to work out a measured way for CCOs to manage the medications, said Ashlen Strong, the manager of government and regulatory affairs for Health Share of Oregon, a CCO that covers Clackamas, Multnomah and Washington counties.

Strong said CCO leaders support the idea of managing psychotropic medications, they just wanted to ensure continuity among the groups and that it would be done in a careful way.

“If we’re managing every part of our member’s health care except for this one particular prescription benefit, that’s just kind of odd,” she said. “It is hard to manage their care if you have this one carve-out of this particular type of benefit.”

Robin Henderson, chief behavioral health officer and vice president of strategic integration for St. Charles Health System, agrees CCOs are the best ones to oversee psychotropic medications, but also felt the most recent bill could have restricted access for patients.

CCOs are always looking to protect their bottom lines and probably would shift patients to generic versions of medications, which don’t always act the same way when it comes to psychotropics, Henderson said.

On top of that, it would have resulted in 16 different sets of prescribing practices, one for each CCO. St. Charles receives patients from all over the state, so that would have created administrative hassles.

“That was not going to work for any of us,” she said.

All of Oregon’s CCOs can access data from the Oregon Health Authority on how many psychotropics are prescribed to OHP members statewide and among their own members through a secure website that’s updated weekly, Andrea Cantu-Schomus, a spokeswoman for the Oregon Department of Human Services, wrote in an email.

Henderson, a former executive director of the Central Oregon Health Council, the group of community leaders that governs the region’s CCO, said while she supports CCOs having access to that data, access alone doesn’t change prescribing practices.

What does is educating primary care physicians, who do the majority of psychotropic medication prescribing, Henderson said. A small group of experts in Central Oregon helped educate doctors on the subject for a while, but it was short-lived. The problem is that improving prescribing practices does not save CCOs money, and they aren’t being provided monetary incentives to do so, she said.

It’s also important to recruit more mental health providers to Central Oregon, something St. Charles is trying to do, Henderson said. Pediatric psychiatrists are in especially short supply locally and statewide.

In the end, Henderson said, CCOs are independent. They don’t like the state telling them how they’re going to handle psychotropic medications. And because people with mental health conditions are an especially vulnerable population, they’re not the ones to be experimenting on with new ways of balancing CCO duties, she said.

She’d like to see stakeholders work together moving forward to reach a solution.

“This is not rocket science,” Henderson said. “We’re just really kind of all stuck in our Oregon tradition of independence, I guess.”