As discussed in the introduction, the present study was guided by three principal questions about the status of pharmaceutical benefits for psychotherapeutic medications. We consider each of these questions in turn.
What are the formal policies and procedures implemented by health care payers that affect consumer access to and utilization of psychiatric medications? Are these policies and procedures different for psychiatric medications than for other medication classes?
The present research indicates that psychotherapeutics are covered on an equal basis with pharmaceuticals of other classes. No evidence of selective application of more restrictive utilization controls, prior authorization requirements, or restrictive formularies was found. These problems appear to have existed in the past, but the policies have been changed in recent years. A few health care payers require that a psychiatrist prescribe psychotherapeutic drugs. Usually this restriction, where it exists, applies only to antipsychotic medications.
How does the implementation of these policies and procedures affect access to and utilization of these medications?
The assertion that access to newer psychotherapeutics is impeded by the implementation of managed care policies and procedures is difficult to substantiate. The evidence from analysis of pharmaceutical claims suggests that, as a group, new generation antidepressant and antipsychotics have diffused into common use at approximately the same rate as have new generation pharmaceuticals in other classes.
However, few healthcare payers have implemented programs to pro-actively facilitate the diagnosis and treatment of mental illness. Fewer still have attempted to measure the outcomes of mental health interventions. The modest programs to support these goals may suggest that the implementation of policies and procedures acts to inhibit access to and utilization of psychotherapeutic medications by consumers who would benefit from them in a more general way. This problem is not specific to the utilization of pharmaceuticals, but reflects a general need for more efforts in providing mental health services.
Do policies, procedures, and modes of implementation (regardless of whether they differ for mental health) create barriers to adequate mental health care even if similar policies, procedures, and modes of implementation do not create similar barriers for adequate care for other conditions?
The concerns of consumers, advocates, and providers suggests that the barriers that are in place to regulate utilization of medications of all classes may be too burdensome for mental health consumers and their providers to navigate effectively. Consumers requiring mental health care may have greater difficulty than some others in asserting their needs and entitlements within complex administrative systems. However, it is possible that a number of other consumer populations with long-term, debilitating conditions would find utilization controls imposed by health care payers difficult to navigate as well. However, the degree to which the mental health services system is burdensome to its consumers has not been compared in any systematic way to the burden imposed by physical health systems on patients with other long-term debilitating conditions.
The impact of pharmaceutical utilization controls or cost-sharing requirements on mental health consumers who may have concurrent physical illnesses is likely to be more severe than it is for consumers without mental illnesses. Mental health consumers are more likely to exceed quantity limits and incur higher dollar amounts in cost-sharing than are other consumers for this reason. This may force the consumer or provider to make a choice between filling a prescription to treat the physical illness and filling a prescription to treat the mental illness. This problem is compounded because providers of mental and physical health services may not be fully aware of all concurrent medications the patient requires. The lack of coordinated care increases the potential for adverse drug interactions, even as it may increase the complexity of how to coordinate care to assure that the patient receives all necessary treatments. This problem is an interesting area for possible exploration.