The Boston Globe
Monday, January 20, 2003
New Massachusetts Drug Copay May Pose Special Risk for Mentally Ill
Jan. 20--Over the 30 years she has been coping with schizophrenia, Veralee Lopez has cut herself, stabbed herself, overdosed on pills, and, once, beat a stranger in a park so severely that it caused a concussion. These days, she lives in her own apartment in Roxbury, meeting weekly with a therapist and a social worker, kept in a delicate equilibrium by a cocktail of two antipsychotic medications, two anticonvulsants, and an antidepressant.
At the beginning of this month, Massachusetts's new Medicaid law began requiring her to help pay for those drugs: $2 a week for each of the 20 medications she takes, including the five psychiatric drugs. Lopez gets $50 a week in federal aid for food, leaving spending money that amounts to $30 -- a sum that would be wiped out by a single copayment.
"It's like I'm trying to live. I am trying," said Lopez, 47. "But where am I going to have that kind of money?"
The $2 copayment, raised from a 50-cent surcharge many did not pay, affects nearly every Medicaid patient in the state who takes prescription drugs. But for severely mentally ill people like Lopez, providers warn, the new charge has special risks. It creates another obstacle for a group of people who already have trouble staying on their medications -- and who can become suicidal or violent if they stop taking them.
"What is already happening is that people don't have money for medication," said therapist Laurie Goldman, who treats Lopez and 26 other patients with schizophrenia or bipolar disorder at the South End Community Health Center. "None of my people are going off their meds, but they are telling me they are going to."
Roughly 75,000 MassHealth members take psychiatric drugs that suggest they suffer from a severe mental illness, according to estimates by pharmacists at the Division of Medical Assistance, which administers the state Medicaid program.
Legally, pharmacists cannot refuse drugs to Medicaid patients, so Lopez can pick up her drugs whether or not she has enough money. But for the mentally ill -- poorly organized and living on extremely restrictive incomes -- the $2 charge could be enough to swing the balance, sending them into medical crises, said Goldman.
Exempt from the copayment are MassHealth recipients judged to be particularly vulnerable: children under the age of 19; pregnant women and new mothers; and those living in nursing homes, chronic disease facilities, and intermediate-care facilities for the mentally retarded. Several providers interviewed argued that severely mentally ill people should be added to that list, to prevent relapses that could lead to suicide, rehospitalization, or violence.
"We don't want to set up any barriers," said Reva Stein, executive director of the Massachusetts Clubhouse Coalition, whose members supply services to 6,000 people with severe mental illness. Some of the people she serves "may just say, 'I can't pay that,"' and go off their psychiatric medications, she said.
The proving ground for the new law will be in pharmacies across the state, where people visit weekly to pick up psychiatric prescriptions paid for by MassHealth. A short walk from the Pine Street Inn in Boston is Tremont Drug, where, according to owner Gary Einsidler, homeless men living at the shelter regularly visit to collect psychiatric cocktails of up to seven prescriptions -- which would add up to $14 a week, or $56 a month, in copayments.
The current law puts Einsidler in a bind: He is not allowed to withhold medicine from his homeless customers because they cannot afford the $2 copayment, and he will not be reimbursed for the sum, either. Instead, the law recommends that providers "bill the member for the copayment," and pharmacists are empowered to "use any legal way" to collect the money from nonpayers, said Rita Sevier, deputy director of clinical projects for the Division of Medical Assistance.
Looking at his impoverished customers, Einsidler wonders how he's expected to do that.
"How can I take someone who has no money to court to get the money?" asked Einsidler. "It puts me in the middle. I'm really not a tax collector."
Under the old, 50-cent copayment, 85 percent of MassHealth recipients paid willingly, and pharmacists absorbed the remaining costs, Sevier said. Since the new copayment went into effect, only three MassHealth recipients have called an agency hotline to complain, Sevier said.
"This is probably one of the lowest copays" for medicine, she said. "Medicaid is still the best deal in town." Senator Richard Moore, Democrat of Uxbridge, has filed a bill that would repeal many of the $2 copayments, along with the $1.30 pharmacy tax that now applies to non-Medicaid prescriptions, said Charlene DeLoach, director of health policy for the Senate Health Care Committee. When the bill reaches committee, DeLoach said, she hopes it will generate discussion on the bill's negative impacts.
James Krasnow, whose Pelham Drug in Brookline serves outpatients at Shattuck Hospital, said many of his mentally ill customers "really are not aware of what's going on to begin with," and are likely to give up the medication rather than spend the $2.
"What you're doing here is you have people on the street who normally in the olden days would have been in a hospital," said Krasnow. "They get, I think, $50 a month to spend, and they spend it on cigarettes," he said. Given the choice how to spend that limited income, he added, "they'll take the cigarettes. It's a Catch-22."
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