As the state of California continues to move forward in supporting people with behavioral health issues, I am writing to suggest some simple, but often overlooked changes that would help people seeking treatment and the health care professionals who provide this care.
Specifically, the California Legislature is considering legislative action that would streamline the approval process for people accessing care through Medi-Cal to receive their prescribed medications for serious mental illness without undue delays.
As a physician who has served our community for more than 25 years, I strongly support this effort.
The concept of prior authorization is just what it sounds like – a medical professional requesting approval from a health insurer or the state prior to prescribing a medication or service for a patient in their care.
It’s important to emphasize how critically important it is to make this change.
Health insurance companies and agencies require providers to request and receive prior authorization for all sorts of treatments before they will agree to cover the cost for the patient. The usefulness of this practice is a topic for another day.
Of interest right now is a common-sense change the California legislature is considering that would eliminate the prior authorization requirement in Medi-Cal for adults living with a serious mental illness whose insurance has already approved the prescribed medication within the past year.
This small tweak – which does not eliminate Medi-Cal’s authority to require prior authorization the first time I might prescribe a drug to a patient with serious mental illness, such as schizophrenia or major depressive disorder – is monumentally important to this patient group. With the leadership of Assemblymember Jackie Irwin, advocates for access to these medications, championed by the California Access Coalition and the Psychiatric Physicians Alliance of California, have been pursuing this change over the last three years.
It’s important to emphasize how critically important it is to make this change. A person living with serious mental illness has unique experiences, including, for example, facing psychosis, which is not common in other forms of mental illness.
These unique factors create additional barriers to treatment because these patients are likely to face additional difficulties in maintaining treatment regimens. When we work with a patient and we find something that works, the smallest change to their routine may lead them to abandon treatment entirely.
The current requirement for us to request and receive intermittent approval for a patient I am already treating with a medication Medi-Cal has authorized is unnecessary and I have seen it knock patients off a path of positive progress leading to Emergency Department visits or hospitalizations that could have been avoided.
This is not a theoretical problem. Doctors have seen prior authorization processes stretch for weeks, during which time a patient’s worsening symptoms push them away from treatment as their symptoms may worsen. We have seen FDA-approved medications for neurological disorders routinely denied, requiring time-consuming interventions to get what should be clear approvals.
We have seen the prior authorization process used to press “fail first” alternative medicines on my patients before they approve the treatment we know will work. Any delay in providing appropriate medicines to the patients we serve may further compromise their health and wellbeing.
As California policymakers continue their efforts to improve behavioral health care in general, I would like to remind them that people most in need – those with serious mental illness who access care through Medi-Cal – cannot be burdened with unnecessary barriers to care.
I urge the legislature to make this small change that will hugely benefit the patients we serve.
Editor’s Note: Dr. Janine Bera is Chief Medical Officer of WellSpace Health.