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Best Practices: Using Best Practices to Manage Psychiatric Medications Under Medicaid

Introduction by the column editor: The two Best Practices columns published here this month present very different approaches for allocating the benefit for psychiatric medications. From Missouri we see a quality assurance strategy driven by the state's Department of Mental Health in which clinicians are given feedback on their prescribing behavior and are encouraged to interact with the process. In contrast, provincial regulators of British Columbia have collaborated with academia to define a formulary that is based on published research that meets predefined outcome criteria. Although in neither case do those involved in these programs really understand the total impact of the program's interventions, in both cases they feel that they are contributing to efficient outcomes. These social experiments stimulate thinking about the management of resources in the face of scarcity. A critical unanswered question highlighted by these two columns is, Who should be involved in the decision-making process? The British Columbia policy is fairly clear on this account: the payer. The Missouri strategy appears to integrate input from clinicians, advocates, consumers, and the manufacturers (Eli Lilly funded the effort). Whom can we trust to decide? Does a selected group of British Columbia academics who are unconnected to the pharmaceutical industry but on salary from the payer enjoy an advantaged perspective for resource allocation? Or should the payer be obligated to include all stakeholders in the decision-making process? Is there adequate knowledge to allow resource allocation strictly via the evidence base? Or should payers be obligated to attend to the realities of individual variability in the treatment of psychiatric patients? Let's hope that nosingle party decides to ration medications in a completely irrational or thoughtless way before we are able to demonstrate best practices for allocating this resource.

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