Policy Research Institute
NAMI POLICY RESEARCH INSTITUTE
STATE ACTION ALERT
February 21, 2003
FAIL-FIRST POLICIES TO LIMIT ACCESS TO MEDICATIONS:
A GUIDE FOR ADVOCATES
NAMI is urging strong opposition to any bills or efforts by the state Medicaid agency to implement "fail-first policies" that requires a person take an older, less effective medication. Only after failing on that drug, which might trigger a serious relapse, may that person be approved for a newer, more expensive – but more effective – medication.
NAMI believes that fail-first policies cause serious medical problems unnecessarily for consumers with mental illnesses.
Advocates should make the following points when addressing legislators or Medicaid officials:
- Controlling costs through fail-first approaches conflicts with most clinical treatment guidelines for mental illnesses. By limiting the array of medication options to consumers, both physicians and consumers are forced to compromise their treatment decisions.
- Often, a consumer will have to fail on one or more medications before they are allowed access to the medication that his or her physician would have tried as an initial treatment. It is poor clinical care to delay the start of effective treatment and expose a person with mental illness to increased risks.
- Fail-first causes unnecessary suffering for people with serious mental illnesses, wastes public dollars and increases the likelihood of relapse.
- Requiring a mental health consumer to fail-first on one or two older medications before an appropriate, newer medication is prescribed is an inhumane method of treatment, unthinkable for treatment for treatment of any other illness. This practice has serious negative consequences for consumers and the public health system.
- Medications comprise a minor portion of the cost of treating serious mental illnesses, but have a major impact on the likelihood of the successful outcome of the care. Furthermore, private health plans have discontinued the use fail-first policies because it did not control costs for payers.
- There are also significant administrative costs associated with these types of policies. But most importantly, consumers can relapse and require more expensive medical interventions such as hospitalization.
- In short, this public policy neglects the extensive scientific research that demonstrates that unobstructed access is a best practice, increases treatment success and thereby saves public funds.
- Significant advances continue to be made in defining appropriate treatment strategies for consumers with severe mental illnesses. Newer medications with fewer side effects and superior efficacy offer encouragement and optimism for the future.
These points can be used in testimony, letters to legislators and in discussions with all state officials involved in decisions on access to medications.