Cost Issues Occupy Intersection of Clinical, Policy Concerns

Last month's Psychiatric Services offers a “spin free” take on the clinical implications of CATIE (see Experts Analyze Real Meaning of CATIE Study Findings). But what do the findings suggest about how society should allocate public dollars for treatment of severe mental illness? And are cost-effectiveness studies alone reliable for making sound public policy?

Surveying the wider landscape of rising American health care costs, Robert Rosenheck, M.D., told Psychiatric News that CATIE suggests that second-generation antipsychotics (SGAs) are not worth the enormous expenditures they have entailed.

“I feel more strongly than most that there is an urgent need for action,” he said. “We as health care professionals tend not to think about money, but taxpayers are paying a lot of money for [SGA] drugs that have been shown to have no greater benefit” than less-expensive older drugs.

“Most people dodge the question by saying we need individual therapies for individual patients, rather than answer the question of what to do about these expenditures,” Rosenheck said. “Atypical psychotropics are not the reason we have a cost problem in the United States, but if we don't address questions of national concern that are in our professional area, how can we expect others to do the same?”

He told Psychiatric News that the VA in Connecticut has instituted an effort to educate clinicians about costs associated with SGAs and to train clinicians in the use of FGAs.

But at the public-policy level, Rosenheck is pessimistic about the prospects for reform.

In a paper in the special section titled “Second-Generation Antipsychotics: Cost-effectiveness, Policy Options, and Political Decision Making,” Rosenheck reviewed several mechanisms for reining in costs: utilization management, pricing mechanisms, and government regulations. For each, he found that political considerations make it unlikely that any of them will be implemented.

Rosenheck concluded that high expenditures for antipsychotic medications are likely to continue without concomitant gains for public health.

But his prescriptions for reining in costs were countered by economist Richard Frank, Ph.D., who argued that cost-effectiveness alone is not sufficient for making sound public policy.

In another report in the Psychiatric Services issue, titled“ Policy Toward Second-Generation Antipsychotic Drugs: A Cautionary Note,” Frank wrote, “It may be premature to adopt such policies primarily on the basis of CATIE results....The advocacy community is painfully aware that payers have frequently seized on uncertainty about evidence of effectiveness to limit mental health insurance coverage, driven partly by economic incentives to avoid enrolling costly patients....It would therefore be wise not to overemphasize a single set of results and to understand the importance of nonscientific input about how policy works in practice.”

In the report “Impact of the CATIE Findings on State Mental Health Policy,” Joseph Parks, M.D., and colleagues described the enormous burden—as much as 10 percent of some states' total pharmacy budget for Medicaid—that funding for SGAs placed on state mental health budgets prior to the appearance of CATIE. The team summarized policy recommendations of the Medical Directors' Council of the national Association of State Mental Health Program Directors in the wake of CATIE. Broadly, they are as follows:

The May issue of Psychiatric Services can be accessed at<http://ps.psychiatryonline.org/content/vol59/issue5/index.dtl>.▪