TO DATE, THE DMA has managed to escape fierce criticism for its poly-pharm-curtailment initiative. Hanson, for one, maintains that the majority of doctors who received warning letters last August embraced the effort. "Letters in response," she says, "have been wonderful." By way of illustration, she quotes several replies written by mental-health directors, psychiatrists, and physicians, all of whom thanked her and promised to review their patients’ drug regimens. "In the past," she adds, "I’ve gotten letters back that were not repeatable. So I’d say people have been very responsive so far."

Clearly, it’s a response that makes sense. Most doctors, after all, are reasonable people who can see the need to be cost-conscious while writing prescriptions, particularly when those prescriptions will be paid for with limited public funds. Even skeptics like Applebaum find it "entirely appropriate" for the DMA to want doctors to prescribe cheaper drugs whenever possible. Pharmaceutical companies can inundate doctors with slick, glossy materials that trumpet the new over the old. Some medications have generated such buzz that they get prescribed for virtually everything but the condition for which they were created. Neurontin, which the federal government has approved for epilepsy, provides a good example. Today, 78 percent of all Neurontin prescriptions go toward "off-label," or unapproved, uses. According to a March 14 New York Times article, the drug’s manufacturer even ordered sales representatives to promote it for 11 off-label conditions, including bipolar disorder — thus yielding a $2 billion windfall in sales this year. Last year, Neurontin ranked as the fourth-most-expensive medicine for the DMA (see "Drug Habit," this page), requiring funding of more than $24 million. Observes Osser, "Doctors get this deafening roar from drug companies. Yet they have a responsibility not to waste precious public resources."

Advocates for the mentally ill, too, have yet to object to the DMA’s effort. Instead, they welcome it as a chance for doctors to review and possibly improve people’s regimens. Toby Fisher, who heads the Massachusetts chapter of the National Alliance for the Mentally Ill (NAMI), sums up the sentiment among advocates best: "If there is clinical proof for doctors to switch one medication for another that’s equally effective yet cheaper, we think that’s appropriate. We support this approach."

Ultimately, though, all this support hinges on one thing: the DMA has stopped short of draconian procedures designed to cut costs by restricting access to medications — for now, anyway. According to the August 12 letters, it hopes to decrease the number of Medicaid recipients on multiple and duplicative psychiatric drugs by as much as 50 percent this November — a percentage that would translate into some $10 million in savings. But because the educational initiative relies on doctors to police themselves, there’s no guarantee it will yield results. Indeed, letters don’t prevent doctors from prescribing more medications or switching to more costly ones. If the agency doesn’t reach its goal, its future steps, says Hanson, are clear: "We will have to implement a prior-authorization policy." In other words, certain psychiatric drugs would require DMA approval on a case-by-case basis before the agency would agree to pay for them.

Such a possibility has already put advocates on alert. Tim O’Leary, of the Massachusetts Association for Mental Health, a Boston-based advocacy organization, explains that he and fellow advocates are monitoring the DMA to ensure that mentally ill patients don’t lose access to critical medications through a prior-authorization policy — which he regards as code for "prior rejection," in view of what has happened in other states. Theoretically, most insurance companies, both public and private, use the prior-authorization technique to make sure prescribed medication is the most-suitable, least-expensive form available. Generally speaking, though, costs drive decisions. Patients who follow the rules — by having their doctors provide letters explaining why they need the drugs — are often denied coverage anyway. Says O’Leary, "Time has shown that the prior-approval process invariably results in denials, denials, and denials."

Even doctors agree that such restrictive policies are a recipe for disaster. The process tends to be time-consuming, onerous, and, ultimately, a deterrent to treatment. How many times a day must a doctor fax off a form that explains why he or she wants to prescribe a certain psychiatric medication? At some point, many will simply throw up their hands and take the path of least resistance by prescribing only those drugs — often generics, often old, and definitely the least expensive — that don’t require prior authorization. "Essentially," says Osser, of the Psychiatric Society, "the only concern with prior approval is saving money," not maintaining quality care. He adds, "I would stand firm against cutting back on psychiatric medications because it could have a counterproductive effect on the patient."

That is what seems to have happened in Michigan, which has one of the most limited psychiatric-drug policies in the country. Last year, the Michigan Department of Community Health, that state’s equivalent of the DMA, drafted a list of preferred psychiatric drugs that can be prescribed by Medicaid-affiliated physicians; medications not on the list require approval before the state pays for them. State officials promised that the plan would not prevent needy people from getting medications. Yet almost as soon as it went into effect in February 2002, patient-advocacy groups began hearing about the fallout. Some people saw their long-time prescriptions denied. Others ended up in the hospital. Still others suffered severe psychiatric collapses.

"The policy has been a terrible burden for people," says Hubert Huebl, the president of NAMI in Michigan. In the six months since the policy’s implementation, Huebl has bumped up against it twice while trying to fill prescriptions for his 32-year-old son, who has bipolar disorder. Only after weeks of phone calls and applications did he get Medicaid to cover his son’s medications. "The state says it’s easy to get approval," he says, "but I can tell you it’s not." Still, Huebl considers himself among the lucky ones. Last April, after fielding frantic call after frantic call, several mental-health organizations in Michigan set up a toll-free hotline to register complaints about the drug list. In eight weeks, they documented 360 calls from consumers and family members. Results show a system that has failed: 66 percent of all people reported that their medication had been denied. Of those who had been forced to switch drugs, 66 percent said they had endured subsequent "negative consequences," including hospitalization. Michigan’s policy, says Huebl, "has generated nothing but trouble. People are getting taken off drugs and switched to others, and it’s not necessarily beneficial."

In Massachusetts, state officials say that they want to avoid such outcomes. The DMA has launched its current initiative because, as Hanson says, "I do not want to be a party to the types of drastic things seen in Michigan and other states." Duckworth concurs: "We’re trying to make sure we preserve access to psychiatric medications." As a psychiatrist, he notes, "I know that if all medications aren’t available, some people won’t get better."

But whether officials can evade a Michigan-type policy remains an open question. In the grand scheme, after all, money counts. The state is financially squeezed as it hasn’t been in a decade. Psychiatric drugs are gobbling up millions of dollars. Something will have to give. In fact, the DMA has already responded to the pressure to rein in ever-escalating Medicaid expenditures by limiting access to all prescription medications except psychiatric drugs. This year, the agency has divvied up other drug categories, such as gastrointestinal medicines and antihistamines, into a list of drugs that either do or do not require prior approval. Says Hanson, "We’re going full blast and trying to put some management back into the pharmacy budget."

Psychiatric-drug prices, it seems, will have to come down, too. If they don’t, as Hanson recognizes, "We will have to cut benefits to other population groups [besides psychiatric Medicaid patients]," such as the 50,000 long-term unemployed who will be dropped from the rolls come March. Medicaid recipients like senior citizens or children could lose all their insurance coverage, not simply their pharmacy coverage. "I certainly do not want us to have to continue to cut people off Medicaid benefits," she says.

It’s a difficult situation, for sure. Hanson and fellow administrators know that any restriction placed on access to psychiatric-medications represents a risky proposition, one that could lead patients to hospitalization, criminal activity, and homelessness. But then, they know that such long-term consequences might not resonate during an unprecedented short-term fiscal crisis — largely caused by the ballooning Medicaid budget. Officials, as the MTF’s Widmer says, "are caught between a rock and a hard place." The measures they must take under enormous pressure to implement meaningful change, he concludes, are "analogous to a finger in the dike when a tidal wave is coming. All they can do is squeeze."

Kristen Lombardi can be reached at klombardi[a]phx.com