Consumer associations report that prescriber credentialling can act as a serious barrier to access to newer psychotherapeutics. Interviews with key informants for this study indicate that there are several cases where health care payers require that a psychiatrist write the prescription for a designated medication. However, these requirements are not widespread and operate almost exclusively in the private sector.
The issue of prescriber credentialling largely applies to antidepressants. Most providers and payers agree that prescription of antipsychotics by primary care physicians (PCPs) is not medically appropriate. Many payers are concerned about inappropriate use of antidepressants for purposes other than the treatment of depression (e.g., weight loss, work performance improvement), and therefore may impose restrictions on the prescription of these agents by PCPs in an effort to prevent this.
- Public Programs
None of the Medicaid or State Mental Health programs interviewed require that a psychiatrist prescribe antidepressants or antipsychotics. The DoD and VA reported that either a primary care physician or psychiatrist can prescribe antidepressants or antipsychotics. DoD did report that some medical treatment facilities restrict prescribing priviledges to psychiatrists. However, this practice is highly discouraged by DoD.
- Private Payers
Private sector insurers indicated a range of prescriber credentialling ranging from moderate restrictions to none. For example, one MCO interviewed requires primary care physicians to obtain psychiatrist approval for prescription for selected antidepressants. At this MCO, these agents include bupropion, venlafaxine, nefazadone, mirtazapine, and monoamine oxidase inhibitors. PCPs may prescribe any TCA or SSRI of their choice without obtaining this approval. Psychiatrists in this MCO have free choice of any psychotherapeutic included on the formulary.
Similarly, one of three PBMs interviewed reported that any outpatient drug prescribed by a psychiatrist is covered without question. However, this PBM requires prior authorization (PA) for all psychotherapeutic prescriptions from PCPs. Other PBMs require no prescriber credentialling.
Although most employers do not become intimately involved with the details of prescribing, Motorola has adopted a more activist approach to meet employee needs and insure quality. In 1995, Motorola embarked on a partnership with Private Healthcare Systems (PHCS) to create a customized network of providers within the Motorola benefits system. To date it has identified approximately 100,000 physicians, 900 hospitals, and 4,000 mental health care providers nationwide who are permitted to prescribe without obtaining special authorization. Employees may nominate new providers on an ongoing basis. After a trial period these providers can achieve the same status as other providers.
- Special Populations
In the New York State prison system, the prison staff psychiatrist or primary care physician manages mental health service delivery. This management includes pharmaceuticals. There are no restrictions on who can prescribe specific prescription drugs.
The Navaho region of the Indian Health Service reported that up until one year ago, only psychiatrists were allowed to prescribe SSRIs. This restriction has been removed. However, the IHS still requires that a psychiatrist prescribe antipsychotic medications.