Physicians across the country are looking to state legislators for help in reducing a painful paradox in the treatment of serious mental illness.
The paradox is stark and simple: Innovative treatments for the 10 million adults with serious mental illness have never been more plentiful, yet insurance barriers are making it harder than ever for patients to access the treatments they need. The most common barriers include:
- Step therapy, also called “fail first,” occurs when insurers require patients to use one or more medications before permitting the clinician-prescribed one. The policy effectively limits access to new, innovative medications until patients first try older, cheaper and potentially less-effective medications that could have unpleasant side effects.
- Prior authorization is another oft-used tactic by payers. It requires prescribers to complete extensive paperwork and provide patient records prior to a patient receiving the treatment. The already lengthy process is often prolonged by appealing denials.
These and other utilization management tactics prolong the time between when a medication is prescribed and when the patient can start taking it. That’s precious time for people who suffer from conditions such as major depression, schizophrenia, bipolar and post-traumatic stress disorder.
Multi-State Legislative Offensive
That’s why the Alliance for Patient Access is supporting legislation in at least 10 states across the country that would completely remove or at least limit these and other insurance barriers for patients with severe mental illness. While bill language differs from state to state, nearly all provide for:
- Simplifying and expediting step therapy and prior approval processes for treatments of mental health conditions if there is no acceptable alternative drug on the insurer’s approved list – called a formulary – or if alternatives have already proved ineffective for a given patient.
- Prohibiting prior authorization if a patient has received approval for the same drug in the previous 12 months.
- Shortening the process. Some bills, for example, enact a 24-hour turnaround provision for insurers to respond to prior authorization requests.
There are finally innovative treatments for patients with serious mental illnesses. But now, it’s up to state legislators to ensure these tools will be available to patients when they are needed.
