Mental Health Summit(1) Concerns about the Four-Drug Limit in Public Act 97-0689, the “SMART Act”(2)

This is a summary of a recently issued Mental Health Summit paper. -Kap

Governor Quinn signed the “Save Medicaid Access and Resources Together (the “SMART” Act) into law on July 1, 2012 to reduce Medicaid spending.  The Act requires that any Medicaid beneficiary receive no more than four medications in any month without prior authorization from the Department of Healthcare and Family Services (DHFS). Consequently, serious concerns about harm occurring to people with mental illness include:

  • More than one psychotropic medication and others may be needed to manage side effects resulting from these medications.
  • Medications may be needed to treat co-occurring chronic illness, e.g., diabetes, hypertension, morbid obesity, hypothyroidism, movement disorders, etc.
  • Medications may be needed to treat non-psychiatric illnesses.
  • Closed mental health centers(3) and movement from nursing homes and other Institutions for Mental Disease (IMDs) to appropriate community housing mandated from lawsuits(4,5) place thousands of persons with serious mental illness into the community who need multiple medications. Restriction to medication access for persons with serious mental illnesses heightens health care costs by increased Emergency Room visits, inpatient hospitalizations and symptom recurrence.

The SMART Act provides additions to the four-drug limit with prior authorization (PA). Unfortunately, the PA system appears unfeasible because:

  • It is not equipped to handle all of the 200,000+ persons with serious mental illness who already take more than four prescription medications.
  • An electronic PA system is not in place to make authorization manageable for physicians to use. Doctors might hesitate to go through the time and expense to negotiate PA to serve their poor Medicaid patients.
  • Illinois has no published standards for PA, further discouraging physician participation.
  • As an interim measure, DHFS made a decision to initiate a temporary ten-drug limit, however, 72,000 Medicaid recipients already exceed this ten-drug limit.

Accordingly, the drug-limit restriction is fiscally unsound and BAD MEDICINE! A dialogue with legislative leaders, DHFS and the community about some prospective changes may avert an impending health care disaster:

  1. Permanently eliminate the four-drug limit.
  2. Amend the SMART Act to exempt the four-drug limit for disabled Medicaid recipients.
  3. Amend the SMART Act to exempt psychotropic medications for disabled Medicaid recipients.
  4. Improve the PA system by creating a viable, transparent PA submissions process with published standards and procedures.

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(1)    Mental Health Summit, 6020 S. University Ave., Chicago, IL 60637,
http://www.law.uchicago.edu/clinics/mandel/mental/summit.

(2)   Senate Bill 2840.

(3)   Tinley Park and Singer Mental Centers.

(4)   Williams v. Quinn – Successful class action lawsuit sought community-living alternatives for residents with mental illnesses in Illinois ordered on September 29, 2010.

(5)    Colbert v Quinn – Successful class action lawsuit sought Medicaid-eligible nursing home residents in Cook County with the array of supports and services that they need in the most  integrated settings appropriate to their needs ordered on December 20, 2011.

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