Incentives to Reduce Metabolic Side Effects of Antipsychotics

To the Editor: Weight gain and related metabolic conditions are common in the population with serious and persistent mental illness. Research has shown that these individuals die about 20 years earlier than those in the general population, with most deaths related to cardiovascular illness. This problem is compounded by the most common serious side effect of antipsychotic medications—weight gain.

Despite widespread awareness of metabolic side effects of medications, researchers have repeatedly found that rates of monitoring are low in mental health practice. Some leading mental health organizations have responded with efforts to increase monitoring and management of metabolic disorders. In the April 2010 issue of Psychiatric Services, Mangurian and colleagues (1) described such an effort by the New York State Office of Mental Health. It is important to ask why such an effort is needed. Why do physicians continue to prescribe medications with metabolic side effects to people who have metabolic syndrome? Well-researched psychiatric rehabilitation strategies to increase wellness and reduce the number and dosage of psychiatric medications are not much followed. Even very obvious strategies, such as switching to medications that cause fewer metabolic complications, are not widely practiced.

Under current financing arrangements, organizations are not provided with incentives to prevent metabolic side effects. The cost of the prescribing physician accrues to the mental health organization; the costs of medications, laboratory tests, and blood pressure monitoring and the cost of management of medical disorders accrue to various other organizations. Preventing metabolic complications saves no costs for the mental health organization. In fact, switching antipsychotic medications or implementing medical monitoring in the mental health setting creates costs that accrue to the mental health organization. Some mental health organizations are acquiring licenses that allow them to provide and bill for medical services. This provides funding for provision of metabolic monitoring and management. However, it still creates no disincentive to prescribing medications with metabolic risks in the first place.

Holding providers accountable for pharmacy costs, mental health costs, and medical costs would provide them with financial incentives to detect and prevent metabolic side effects and lower medical costs. Savings could then be used to provide the evidence-based psychiatric rehabilitation practices needed to reduce the number and dosage of medications. Accountable care organizations (ACOs) could be structured to address metabolic side effects. There is now a division between acute and well care and long-term care. A disease caused during acute treatment is billed in long-term care. Extending the period of acute and well care to include sufficient time to make ACOs responsible for side effects from improper use of psychiatric medications would create incentives to reduce these effects and save monies, which could be used to pay for medical monitoring and rehabilitation interventions.