For Schizophrenics on Medi-Cal, a Dose of Good News

Californians who are schizophrenic and on Medi-Cal saw their fortunes improve significantly last week.

A new regulation went into effect on Wednesday, granting Medi-Cal beneficiaries with schizophrenia and other psychotic illnesses the right to receive any one of three highly effective medications that had previously been available only with special approval.

The state Department of Health Services had refused to add the three drugs--which represent a new and revolutionary approach to treating schizophrenia--until intense, statewide pressure from mental health activists, patients, families and physicians forced a resolution to the problem.

California is one of the last states to make the expensive medications, called “atypical antipsychotics,” available.

“In nearly every other state, [mental health activists] didn’t have to do what we had to do to get these drugs made available under Medi-Cal. The state was unbelievably resistant. It took an enormous effort,” says Rusty Selix, executive director of the Mental Health Assn. in California.

Selix, who is also director of the California Council of Community Mental Health Agencies, is largely credited for steering the agreement through the Department of Health Services.

The three medications now available to schizophrenics are Clozaril, Risperdal and Zyprexa. The state also agreed to review each new antipsychotic coming onto the market (a fourth atypical antipsychotic, Zeneca Pharmaceuticals’ Seroquel, was approved for use last week) for addition to the Medi-Cal drug formulary.

Under the previous guidelines, Medi-Cal authorities had to review and approve every prescription for the newer drugs, usually requiring proof that the patient had tried two of the older medications without improving.

An estimated 24,000 Medi-Cal beneficiaries had obtained the medications through the prior authorization process.

But, notes Richard Van Horn, executive director of the Mental Health Assn. of Los Angeles: “You couldn’t get these drugs without the two failures. You also had to document that the treatment was a failure. That takes a long time. So you’ve already subjected the person to a pretty long period of time before asking for the newer drugs. But why should someone be forced to suffer when there is a better alternative out there?”

With the red tape gone, the number of Medi-Cal recipients using the new medications is expected to double, according to the Department of Health Services.

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Schizophrenia is frequently described as the most tragic of mental illnesses. The disease typically strikes people in high school or college and causes horrendous symptoms such as hallucinations, delusions and paranoia. Before Clozaril, Risperdal and Zyprexa became available earlier in this decade, people with schizophrenia and psychotic disorders typically received the medications Haldol and Thorazine, which have been in use since the 1950s.

Haldol and Thorazine are usually helpful in relieving some of the worst symptoms--among them, hallucinations--but they fail to address other symptoms, such as apathy and withdrawal. The older medications also cause debilitating side effects, including muscle spasms, jerking and the inability to sit still.

However, Clozaril, which was the first of the new antipsychotics, was so effective at treating a broad spectrum of symptoms that doctors and families in the early 1990s soon began to tell of patients “awakening” from their illnesses and picking up the pieces of their lives.

Studies have demonstrated that patients on the newer medications have a twofold increase in their ability to return to the workplace.

“These drugs are the most miraculous I’ve ever seen,” Selix says. “The difference they make in people’s lives puts them in a class by themselves. They focus on the people who are the most disabled people in our society. Many people awaken after decades of being in a semi-dazed state to become as smart, active and high functioning as they would have been.”

The problem of when to add expensive, but revolutionary, new drugs to the Medi-Cal formulary is not a new one. The state and mental health activists clashed on a similar problem a few years ago when doctors and families began seeking approval to use the newer class of antidepressants called “selective serotonin reuptake inhibitors,” which includes Prozac.

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While the newer antidepressants are thought to be similar in effectiveness to the older versions, they cause far fewer troublesome side effects.

With minimal prodding, state authorities added several of the new antidepressants to the Medi-Cal formulary last year.

State officials rarely hesitate to add a new medication to the formulary, says Stan Rosenstein, assistant deputy director for Medi-Cal.

“This sort of problem is rare,” he says. “It could also occur with new drugs for cancer or AIDS [which also tend to be very expensive]. But we put most new drugs for cancer or AIDS on the formulary.”

Why then discriminate against making expensive new drugs for mental illnesses available to Medi-Cal recipients?

According to Rosenstein and mental health activists, the problem is not one of discrimination against mental illnesses but one of Medi-Cal regulations designed to control costs. New medications are typically added to the Medi-Cal drug formulary after a review of their cost-effectiveness. Another stipulation is that enough similar medications must be available to allow state officials to bargain for the best possible prices among various drug manufacturers.

After Risperdal and Zyprexa joined Clozaril on the market, mental health activists and physicians were able to gather data to show the state that the newer drugs were cost-effective, Selix says.

The testimony before the state included a USC School of Pharmacy study that predicted a $17-million annual savings to Medi-Cal by allowing the new drugs onto the formulary. While the older drugs cost about $1,000 a year, compared to $2,700 a year for the newer medications, the savings is accumulated by the reduced hospitalizations, doctors’ visits and pharmacy costs.

“It was a very effective process,” Rosenstein says. “We involved the mental health community. The drug manufacturers were very cooperative in giving us information on the drugs and price information. And we got the best prices possible.”

Both the state and the mental health community got what they wanted, Selix notes.

“In fairness to the state, they had set up a process designed to control drug costs. It works well at controlling costs, but it doesn’t work well when you’re trying to look at how your potential savings will outweigh the costs. The state says you have to prove to us that these savings will outweigh the drug costs,” he says.

“In the end, we want to express our appreciation to the Department of Health Services for coming around and allowing the mental health community to have access to these drugs while still preserving the structure of a program that they believe in.”