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ACA reform must preserve mental health pharmacy access


ACA repeal or replacement must focus on how to preserve mental health services and pharmacy access.

Despite efforts to destigmatize mental illness, patients who seek psychiatric care face more barriers to care than those with physical disorders. Yet just last month, in one of the first actions related to repealing and replacing the Affordable Care Act (ACA), the U.S. Senate considered a proposal to reduce or eliminate access to mental health services-an initiative that would severely impact mental health patients’ access to pharmacies and drugs.

Read: Mental health: The secret sauce to healthcare reform

Any discussion in Washington, D.C., on repeal or replacement of the ACA must focus on how to preserve, not curtail, mental health services and pharmacy access as essential benefits for all beneficiaries, including individuals with pre-existing conditions. Anything less is discriminatory against individuals with mental illness.

In 1996, Congress passed the Mental Health Parity Act and strengthened it through the Mental Health Parity and Addiction Equity Act in 2008. More recently, the ACA established policymaker intent in mental health parity, mandating mental health services and addiction treatment, as well as pharmaceutical access, as two of 10 essential health benefits.

An estimated one in five Americans depends on psychotropic medications to stabilize their condition. When access to these drugs is limited, the results can be disastrous. Approximately 30% of mental health patients who face barriers to accessing medications experience treatment lapses or discontinuation. Two recent studies that examined restrictions on medication access and psychopharmacologic treatment on individuals with Medicare or Medicaid showed that 69% of patients had adverse events, including significantly higher rates of emergency room visits, hospitalization and worsened side effects that interfered with functioning. These events result in higher costs for payers from avoidable complications.

There are a number of barriers that impede medication access, including a complex insurance system and cumbersome requirements by some payers to re-categorize long-acting injectable antipsychotic medications and other critical injection medications as “specialty” medications, necessitating them to be filled by mail-order. But the ACA helped to mitigate the most significant barrier: people can’t take medication to manage their behavioral disorders if they can’t access mental healthcare services in the first place. An estimated 30%  of individuals who received coverage through the ACA have a mental or substance use disorder, according to the federal Substance Abuse and Mental Health Services Administration. By mandating preventative screenings, therapy and medication, the ACA helped individuals access services for mental health and addiction treatment at early stages, when they are more likely to adhere to their medication regimen.

Another important benefit of the ACA is that it directed millions to Community Mental Health Centers (CMHC), with a specific focus on integrated behavioral health services in primary care. Under the integrated model, pharmacy services are often embedded right into behavioral health centers, facilitating collaboration between pharmacies and providers on treatment plans for patients. This model is radically successful in facilitating access and adherence to medication, and mitigating avoidable adverse events. A 2016 peer-reviewed study published in the Journal of Managed Care and Specialty Pharmacy showed that integrated care models that feature onsite pharmacies within CMHCs produce higher medication adherence rates than community pharmacies, as well as lower rates of hospitalization and lower emergency department utilization.

President Trump promises to move quickly and decisively to repeal the ACA, but he also promises “insurance for everybody.” That’s encouraging, but healthcare stakeholders, including payers, should take note of the social and financial value of pharmacy benefits, supporting them as a critical component of ACA reform and all aspects of healthcare policymaking. It is only when we, as a society, passionately and vigorously protect these benefits that we can claim there is true parity for the mentally ill-a clear benefit for our entire society.


John Figueroa is chief executive officer of Genoa, a QoL Healthcare Company, and a member of the Board of Visitors of Pepperdine Graziadio School of Business and Management. The third annual Pepperdine Graziadio Future of Healthcare Symposium will be held in Los Angeles in March 23, 2017, featuring Ezekiel Emanuel, MD, one of the principal architects of the ACA.

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