Buried in Gov. Andrew Cuomo's proposed budget for New York is a cost-cutting measure that would empower the state and health insurance companies to deny low-income mental patients the specific brand-name anti-psychotic drugs their doctors prescribe, in favor of less expensive versions.
Some care providers worry that some of those patients could be dangerous without an effective drug or if they stop taking it. The proposal would cover anti-psychotic drugs for patients suffering from an array of mental illnesses including schizophrenia, bipolar disorder, personality disorders and deep depression.
"The additional hoops we have to go through may mean their symptoms go on longer," said Dr. Anna Lamb, a primary care physician in Batavia and president of the New York State Osteopathic Medical Society.
"They may become less functional," Lamb said. "In the mental health world, it can be very frustrating because you run the risk that the drugs may not be effective, or have side effects ... the idea is to help them become productive members of society."
Cuomo insists that eliminating the "prescriber prevails" power wielded by physicians will pose no public threat, noting that the state's preferred list of anti-psychotic drugs includes 13 brand names.
The state already requires less-expensive generics when they are proven to work as well as brand names, but in the anti-psychotic drug class there are few generics. The New York conflict is between competing brand-name drugs, some of which are cheaper. If the cheaper drug fails first, a patient could appeal for his or her preferred drug.
The Cuomo administration and the medical experts serving his Medicaid "redesign team" say each is effective for the poor and elderly patients served by the government health care system. And the anti-psychotic drugs are also prescribed for less serious disorders, such as insomnia, dementia and mild depression.
The measure would save $9 million in state funds. It's part of Cuomo's $143 billion budget proposal, which also includes spending increases such as an extra $420 million in tax breaks for movie productions through 2019.
It follows another cost-cutting attempt from last year's budget in which some female Medicaid patients were told they had to switch from their preferred brand of contraceptive to lower-cost options unless the cheaper measures failed, resulting in pregnancy, bleeding or nausea.
After protests by women, the administration reversed itself and ordered insurers to cover preferred contraceptives.
Health insurers, industry experts on the redesign team and more than a dozen other states see such changes as not just cost-effective, but also better for patient care.
Cuomo is also concerned about the inappropriate prescribing of anti-psychotic drugs, which can have serious side effects. Officials said as many as half the prescriptions for anti-psychotic drugs are done by general practitioners, not psychiatrists.
Cuomo doesn't want primary care physicians to overrule the choice of managed care companies that use experts in the field.
Lamb, however, said primary care physicians are often charged with the care of patients after they leave psychiatric hospitals, especially in rural areas with few psychiatrists.
The governor is expected to address that concern. He is planning to propose a "gold card" program in which highly trained psychiatrists could make quicker decisions from a remote location if there is a conflict in an area without psychiatrists to consult.
In the meantime, patients would be able to appeal to get the specific drug they prefer, but that could take weeks.
Cuomo's proposal "conforms Medicaid-eligible drugs with the federal guidelines and accepted science," said Cuomo spokesman Rich Azzopardi. "This will protect patients while also removing opportunities for waste and abuse in the system."
Cuomo's proposal comes a week after a new state law was enacted that requires therapists to more aggressively report any dangerous comments by mental health patients involving guns.
"It's very frustrating to me after we just spent time on how important the mental health issue is in the big picture of gun violence," said Kathe LeBeau, a patient advocate who has experience as a care provider for mentally ill patients. "This seems to be diametrically opposed to that effort."
LeBeau is part of an effort by health care providers to persuade Cuomo to eliminate the proposal during a 21-day period to amend his budget. The group is also lobbying legislators who will negotiate a final budget by April 1.
"From a patient's perspective, you are not as invested in your therapy because you lose confidence — you already are taking something your doctor doesn't think is best," LeBeau said. "In a crisis, it's hard enough to get people to take medication. ... This is a class of drugs specifically for patients who are probably the most vulnerable."