Cash-strapped lawmakers in Missouri, Kansas and across the country maintain that the costs of Medicaid-provided drugs are escalating wildly out of control, costing taxpayers hundreds of millions of dollars each year.
They want to take a closer look at the prescription-writing habits of Medicaid providers to find out if all those pills are necessary.
Some of the most heavily prescribed are mental health drugs, such as Abilify, Seroquel and Geodon. In Kansas, four of the top five prescribers of Medicaid-funded mental health medicines are in Wichita, according to a Kansas City Star analysis.
"Taxpayers are footing the bill," said Sen. Charles Grassley, an Iowa Republican. "Government officials running the programs have an obligation to determine whether fraud is involved and fix whatever might be broken."
Mental health care providers understand concerns about costs, but insist the drugs they are providing have fewer side effects and work better for those who need them. They also note that the recent Arizona shooting of a congresswoman and others shows the need to make medicines more readily available to the mentally ill, not less.
"I understand the concern. I'm a conservative," said Patricia Gleue, a pediatric nurse practitioner in Lawrence, and one of the biggest prescribers of Medicaid mental health medicines in Kansas, according to state records. "But these drugs are very superior to the old anti-psychotics."
The debate is likely to end up in the Missouri and Kansas legislatures, where lawmakers are struggling to balance their budgets. Half of this year's budget shortfall in Kansas — $250 million — came from increased demands for Medicaid, including prescription drugs.
"We will take a look at it," said Kansas Lt. Gov. Jeff Colyer, who will lead a study of the state's Medicaid spending. "It's one piece of the problem."
Medicaid is a federal-state partnership providing health care services to people who meet low-income and family guidelines that differ among the states. Generally, the federal government pays 60 percent of the cost of Medicaid services, with states picking up the rest.
Prescription drugs are a big part of the program's cost. Kansas will spend about $166 million on Medicaid prescriptions this fiscal year; Missouri will spend about $874 million.
Much of that spending — estimates are as high as 40 percent — will go for medicines that counteract schizophrenia and other serious mental diseases. But costs for those newer mental health medicines are growing at four or five times the rate of inflation.
Those rising expenses prompted Grassley last spring to write all 50 states asking for a list of their top 10 Medicaid prescribers of Abilify, Geodon, Seroquel, Zyprexa, Risperdal, OxyContin, Roxicodone and Xanax — drugs he linked to increasing taxpayer costs.
"The overutilization of prescription drugs... plays a significant role in the rising cost of our health care system," wrote Grassley, a member of the Senate Finance Committee.
Officials in Missouri and Kansas assembled lists responding to Grassley's request. But in both states, the prescribing doctors were listed only by number, not by name.
The Star filed open records requests in both states, asking for the names of the providers. Both states complied.
In Kansas, the top three prescribers of Medicaid mental health medicines in 2008-09 were Rex V. Lear, Deann Jenkins and Lin Xu. All work at Comcare of Sedgwick County in Wichita, one of the state's largest providers of mental health services for Medicaid-eligible patients.
Combined, the three doctors were responsible for Medicaid mental health prescriptions worth nearly $5.2 million, state records showed.
Marilyn Cook, Comcare executive director, said all three doctors would not comment on their prescription-writing records. Cook also cautioned that the state's data might be misleading because it could include prescriptions written by each doctor's assistants, but attributed to the three physicians by pharmacies.
Cook acknowledged, however, that Comcare was one of the highest Medicaid prescribers in Kansas. She said the mental health drugs were essential for treating their patients.
"This is data on volume. It does not address quality," she said. "Our docs are very careful about the scripts they write." The doctors in the clinic, she said, are "very seasoned psychiatrists."
The fourth-highest Kansas prescriber, Bal K. Sharma, has an office in Kansas City, Kan. Sharma, who wrote scripts costing $1.06 million, did not return calls.
The fifth-highest prescriber was Garry Porter of Wichita, whose Medicaid prescriptions cost $1.02 million over the two-year period, according to the Star's analysis.
Porter said the prescriptions were justified for "very sick" patients at several different clinics, recipients who might have ended up in the hospital without the drugs, costing taxpayers even more money.
"Those are expensive drugs, so it doesn't take long for it to mount up," he said.
Cost of drugs
The higher cost of such drugs as Abilify is well known to hundreds of thousands of people who use the medicine and often face co-pays of $100 or $200 a month for their prescriptions.
Co-pays for Medicaid patients, however, are much less, in some cases $2 or $3. That means Abilify users on Medicaid pay far less for their drugs than those who rely on private insurance — the very people whose taxes pay for Medicaid.
But policy makers acknowledged it would be tough to remedy that discrepancy, because the poor people getting the drugs are often quite ill.
"All of those folks are on a close edge," said Missouri Gov. Jay Nixon. "A responsibility of government is to make sure that medically, they're controlled and able to live as normal a life as possible."
Others said the differences deserved closer scrutiny.
"There's no question that Medicaid recipients have better access to care than other low-income individuals who are uninsured. That's why taxpayers and policy makers created the program," said Andrew Allison, director of the Kansas Health Policy Authority, the body that oversees the state's Medicaid program. "Having said that, I... think it is legitimate to ask if some Medicaid patients could afford to contribute more to the costs of their own care."
Yet the ability of Medicaid patients to receive relatively expensive drugs at low out-of-pocket costs suggests the possibility of fraud, according to Grassley and other critics. They worry that some Medicaid patients would resell the drugs and keep the difference.
Nanci Gonder, a spokeswoman for the Missouri attorney general's office, said officials had little direct evidence of Medicaid prescription drug fraud, although illicit resale of prescription drugs is not "overly uncommon."
Obstacles to savings
Obstacles in the way of saving Medicaid money are high. Laws in both states specifically prohibit government officials from limiting access to mental health medicines — measures that advocates contend protect mentally ill people and critics argue only increase drug company profits.
In a statement, the Pharmaceutical Research and Manufacturers of America said both states had worked to improve their Medicaid drug programs.
"It is vitally important that physicians have a voice in the process since, in the end, they know best the needs of their patients," the group said.
Those working with health care providers said lawmakers should weigh any decisions carefully before drastically reducing spending on drugs for those who need them.
"The mental health people say if you use cheaper drugs, people die. They commit suicide," said Charles Shields, a former Missouri lawmaker who is now chief operating officer at Truman Medical Center-Lakewood. "You have to be very careful that you don't create other costs downstream."