Access and Utilization of New Antidepressant and Antipsychotic Medications. Continuity of Care and Coordination of Benefits


Consumer associations expressed concern that patients were forced to change medications when the transitioning between treatment settings (e.g., inpatient to outpatient) because of formulary restrictions, or when transferring among payers. These associations were also concerned that the agents used in inpatient settings were chosen more for cost reasons than out of concern for appropriate care. Provider associations indicated that it was common to change a patient's medication when the patient is admitted to inpatient treatment, largely because the admission likely indicates that current therapy is not working. Respondents from the pharmaceutical industry indicated that coordination between inpatient and outpatient care was a problem in the past, but that this issue has resolved with increasing access to newer agents.

The choice of psychotherapeutic agent in an inpatient setting likely plays a role in the ultimate treatment choice for many, but certainly not all, patients with mental illnesses. Individual hospitals will have internal formularies that are not subject to the allowances or restrictions of health care payers. Therefore, it is quite possible that the agent used to stabilize a patient after a hospital admission will not be on the formulary of the patient's health care payer when discharged. Payers have differing ways of approaching these scenarios, although in most they did not perceive the issue to be much of a problem. This disconnect between perceptions of consumers and providers and those of payers suggests a need for more extensive follow-up research, public education, or payer training on these issues.

  1. Public Programs

    State programs were unaware of any problems with continuity of care between treatment settings. This is likely because most State programs have open formularies (see next section). Likewise, State programs were unaware of any systematic differences between the pharmacy benefit coverage between Medicaid and State Mental Health programs, as these often work off the same formulary and route purchases through the same channels. In two States (AZ, MD) Medicaid has assigned authority for behavioral health services to a single state agency for mental health, leading to nearly seamless coordination between the two programs. State Mental Health programs more actively coordinate pharmaceuticals between inpatient and outpatient than do Medicaid programs.

    Similarly, the DoD and VA reported no issues with continuity of care between inpatient and outpatient settings. In fact, the VA requires that outpatient clinics follow treatment protocols established for the patient during hospitalization. In order to assure continuity, the VA requires that a VA physician be consulted prior to a patient's refilling a prescription in an outpatient clinic after release from an inpatient setting.

  2. Private Payers

    Private payers uniformly report that coverage for psychotherapeutic agents is no different between inpatient or outpatient settings. One MCO specifically reported explicit allowances for patients to continue taking non-formulary drugs upon discharge from the hospital. However, hospital formularies may dictate the choice of drugs available to the patient in an inpatient setting, independent of the insurer's formulary. Hospital formularies are usually hospital-specific and health care payers do not generally have any direct say in their composition.

  3. Special Populations

    The Indian Health Service reports no difference between its inpatient and outpatient formularies. Therefore, if patients are treated within IHS inpatient hospitals or day treatment facilities, they will have no coordination issues. However, inpatient psychiatric admissions are contracted to other facilities. In these cases, the IHS will attempt to switch patients from non-formulary drugs started in hospitals to agents of similar class when they transition to the outpatient setting.