Access and Utilization of New Antidepressant and Antipsychotic Medications. Provider and Patient Compliance


  1. Programs that monitor patients for compliance with therapy or providers for compliance with treatment guidelines are in their infancy.

    • Provider compliance is a greater priority within the private sector than the public sector.
      • Provider compliance programs generally do not operate in traditional Medicaid programs. Any willing provider (AWP) legislation generally excludes the possibility of provider credentialling.
      • State Mental Health programs do not monitor their providers for compliance with treatment or prescribing guidelines on a statewide basis. These programs often are implemented at the level of the individual hospital or community mental health center.
      • The DoD and the VA are more aggressive in monitoring provider practice patterns. Both routinely review provider records to monitor for compliance with formularies, evaluate dosing patterns, and monitor inappropriate use of medications at the treatment facility level.
      • Although most payers interviewed use formularies and treatment guidelines primarily as educational tools, several do enforce compliance. Both incentives and disincentives are used to encourage provider compliance, although these practices appear to be less common than many fear.
        • Many plans are beginning to implement comprehensive disease management programs that include a provider component.
      • PBMs generally do not enforce physician compliance with treatment guidelines or disease management programs, but encourage compliance through education and notification.
        • Maintaining patient confidentiality often precludes adequate data collection and monitoring on a case-specific basis.
      • Employers monitor providers for compliance with guidelines via concurrent or retrospective DUR. Furthermore, employers may partner with their PBMs or HMOs to conduct provider education.
    • Patient compliance and disease management programs appear to be more common in the private sector than the public sector. Compliance or disease management programs are less common for schizophrenia than they are for depression.
      • Patient confidentiality remains a barrier to the effective implementation of disease management programs. This is especially true in the public sector
      • Manufacturers focus on physician compliance rather than patient compliance due to concerns for patient confidentiality and greater ease of tracking physicians.
        • Patient compliance and disease management programs have not necessarily proven financially beneficial to manufacturers.
      • PBMs, MCOs and employers are beginning to implement case management programs for depression and to a lesser degree, schizophrenia, even though case management is often delegated to behavioral health carve-outs.
        • Programs that focus on screening and diagnosis are more common than those that actually focus on case management.
      • Employer-sponsored programs designed to assist patients in recognition and treatment of mental illness are not as common as physician-targeted programs.
        • Employers expressed reluctance to implement these programs due to patient confidentiality, the difficulty of data acquisition and the difficulty of demonstrating value of these programs.
        • Employee assistance programs (EAPs) play a primary role in the detection of mental illness, acting as triage networks and referral mechanisms.
      • Once employees are undergoing treatment for mental illness, BHO carve-outs may provide generic case management.
      • PBMs are reluctant to operate patient compliance programs due to confidentiality concerns. However, one PBM offers compliance assistance for antidepressants and will survey physicians for effectiveness.


The patient-targeted programs that do exist do not generally take into account cultural differences in populations that may affect the success of these programs.

The management of patients who become severely mentally ill is not uniform across service sectors. There are few special programs for these patients.