Medicaid drug restrictions thus far seen as bitter pill for patients, providers

MedicaidPharmaceutical IndustryChemical IndustryCrime, Law and JusticeJustice SystemPersonal IncomeJim Parker

To illustrate the early problems the state is having as it makes large-scale cuts to its Medicaid program, consider the new limit on prescription drugs.

For the most part, low-income people used to be able to get an unlimited number of prescriptions filled. Now there's a maximum of four a month.

That's a problem for mental health patients who may take a cocktail of six or seven drugs a day, from psychotropic medicines to control mood and behavior to prescriptions to suppress unwanted side effects.

While the new law allows for doctors to write more than four prescriptions a month for those who need it, they must get prior approval — a process health care professionals say the state has yet to detail and is ill-equipped to handle.

The limits were scheduled to go into effect July 1 with the goal of saving $180 million a year, a significant part of a planned $1.6 billion in Medicaid cuts. The state also is putting in place new restrictions on a wide range of services — including narrowing who qualifies for dental care and podiatry visits and limiting how often a person can receive new eyeglasses or qualify for wheelchair repairs.

But it's the prescription drug limit that has gotten the most attention. Doctors and clinics say they have received little direction from the state on how to carry out the changes, adding confusion to a process that's already painful for many.

"We're just waiting. … We have no indication that they are ready to flip the switch," said Bruce Seitzer, chief clinical officer at the Community Counseling Centers of Chicago, which provides mental health services for 10,000 adults and children a year, 97 percent of whom are Medicaid patients.

Seitzer said requiring doctors to get approval to prescribe medication will unnecessarily "complicate" the doctor-patient relationship with an added layer of bureaucracy.

Mark Heyrman, a professor at the University of Chicago Law School, goes a step further. He says the prescription limits amount to a "denial" of service, saying Medicaid doctors already are reimbursed at such low levels that many do not have the staff or time to navigate an advance-approval system for their patients.

Lawmakers who negotiated the Medicaid changes said the limits were meant to stop doctors from overprescribing and ensure that medical providers reviewed patients' medications to prevent adverse reactions.

Heyrman has his doubts.

"It either shows that doctors are overprescribing medications — of which there is little evidence — or it will save money because the doctors will give up," said Heyrman, who is a plaintiff in a lawsuit against the state to ensure that money saved from the closure of the Tinley Park Mental Health Center will be reinvested in community-based services.

Providers also question how much money the state will actually save by restricting medication, saying patients who don't get what they need could turn to more expensive emergency rooms for treatment.

"The patient will have to pick which medication they will take ... and they need them all," said Anthony Bucki, manager of emergency medicine for Ingalls Health Systems in Harvey, where the majority of patients are on Medicaid or Medicare. "There will be repercussions in the ER, where we provide more expensive care. This is not a cost savings. ... It's more of a cost-shifting."

Rep. Patti Bellock, a Republican from Hinsdale who helped negotiate the state health care overhaul, said lawmakers are aware of the concerns. But she said changes had to happen to save the Medicaid system from collapse. The overall proposal includes the widespread cuts and a $1-a-pack cigarette tax increase.

Bellock said lawmakers took cues from other states and the private insurance industry when making cutbacks but acknowledged that unforeseen circumstances may arise when widespread changes are made so quickly. She asked for patience, saying it will take time to implement the new rules.

"The bottom line is, we are trying to make the system better, because the way it stands right now, it's totally broken and can't be sustained," Bellock said. "We feel we made the reforms in the most responsible manner we could, but we know it may need adjustments."

Jim Parker, deputy administrator of medical programs for the Illinois Department of Healthcare and Family Services, which oversees Medicaid, said the agency is working to make the pre-authorization process as easy to navigate as possible.

He said the state already has a pre-approval system in place for doctors who prescribe drugs that are expensive or highly abused. The department is testing an online system to handle the expected flood of new requests. In the meantime, doctors can seek approval by calling the state or faxing in the needed paperwork.

Parker conceded there might be some confusion but said the department has done its best to reach out to health care providers through its website and online mailing system. The agency no longer mails paper notices to providers informing them of program changes because it was too expensive.

"It's a lot of change of once; we are aware of that," Parker said. "We are attempting to accomplish many things that the legislation implemented in a short amount of time. But … some of these are overdue reforms to control things the way that (private insurers) have been doing for years."

Another change includes limiting the number of sessions patients can receive for physical, speech and occupational therapy. Instead of unlimited visits, they are now limited to 20 sessions a year.

While providers acknowledge that some changes were needed, they say the pendulum has swung too far in the opposite direction. They contend that not enough emphasis was put on diagnosis, arguing that someone who suffers a stroke will face the same limits as a person with a sprained knee.

The problem with that, according to one expert, is that a stroke patient might need 20 visits just to get through the first few months of rehab.

In the early stages, therapy needs to be more frequent so the patient can build new pathways to improve function. Then, as abilities improve, the sessions eventually taper off, said Vince Cesaro, director of physical therapy at Little Company of Mary Medical Center in Evergreen Park.

"We're not talking about playing golf or tennis," Cesaro said. "We're talking about being able to tie your shoes, feed yourself or get out of a chair … the things you need to get through your life."

One patient, a 40-year-old technician, was undergoing occupational therapy at the hospital after a wrist injury. "If I don't have enough rehab, I'm afraid I'll be limited in the use of my left hand and I won't be able to work," said the Oak Lawn man, who did not want his name used for fear he would lose his benefits.

Parker, of the state Department of Healthcare and Family Services, said doctors will be able to request more sessions if patients need them but added that if health care administrators do not sign off first, providers will have to pick up the extra cost.

Supporters of the Medicaid changes say they know it's a difficult time for providers and patients alike, but they hope the changes will bring about a different approach to health care in Illinois. Instead of the state rubber-stamping medicine and treatment, they hope restrictions will put more emphasis on preventive care — a sea change they hope ultimately will save money, even if the transition is rocky.

"We have no money," said Rep. Sara Feigenholtz, a Chicago Democrat who sponsored the overhaul. "We did this all in one fell swoop, and we're going to have to come back and probably correct a few things."

mcgarcia@tribune.com

brubin@tribune.com

Twitter @moniquegarcia

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