Patients with schizophrenia face a cascade of systemic failures, from insurance barriers to fractured electronic records to injection site shortages, that undermine even the most carefully designed treatment plans, according to Michael McGuire, PharmD, professor of pharmacy practice at Belmont University College of Pharmacy and Health Sciences and practicing psychiatric pharmacist at an inpatient behavioral health hospital in the Nashville area. In this Q&A with Pharmacy Times, McGuire explains how pharmacists can play a critical role in overcoming some of these barriers, specifically regarding the use of long-acting injectables (LAIs) for patients with schizophrenia.
Pharmacy Times: Can you please introduce yourself?
Michael McGuire, PharmD, BCPP: Hi, my name is Michael McGuire. I'm a professor of pharmacy practice at Belmont University College of Pharmacy and Health Sciences. I've been at Belmont since 2012. I practice at an inpatient behavioral health hospital in the Nashville area, where I've practiced for almost the entire time I've been at Belmont. I also have a small outpatient clozapine clinic where I do point-of-care testing for patients on clozapine. I'm a Board Certified Psychiatric Pharmacist, and I'm also a fellow of the American Association of Psychiatric Pharmacists.
Pharmacy Times: What are the most persistent barriers to effective schizophrenia treatment that you see in practice today, particularly from a medication access and adherence standpoint?
McGuire: Well, there's several. One of the most consistent things that I think we continue to experience are prior authorizations. They remain a significant barrier for us. Schizophrenia is very much a heterogeneous disorder. Every individual who has this illness is different. The treatments are also heterogeneous. What works for one patient is what works for one patient. It is so often trial and error for us to find what works, and oftentimes we have to try different things. So prior authorizations do present a barrier, particularly if there are long-acting injectable medications that we want to initiate. If there are new treatments or new mechanisms, getting those approved can sometimes be a challenge for us.
Something that I've also encountered lately is a shift in a number of the long-acting injectable antipsychotics from being covered under a pharmacy benefit on an insurance plan to being covered under a medical benefit. Many pharmacies don't have the capacity to submit for authorization under a medical benefit, so when we've had that come up, that treatment is just not available for a patient. The other thing that I continue to encounter is a breakdown in the transition for patients between outpatient and inpatient care, and from inpatient to outpatient. Individuals with schizophrenia struggle with cognition. They struggle with navigating the complexity of the health care system, and so we encounter errors that happen all the time. Medications get missed. It is a real difficulty for these individuals to navigate. It's difficult for us as health care professionals to navigate a fractured system, so if I'm a patient, I have a hard time navigating it, much less if I have schizophrenia.
Pharmacy Times: How can long-acting injectable (LAI) antipsychotics help address some of these challenges, and where do you see gaps in their current utilization?
McGuire: I work in a hospital, and we often try to initiate long-acting injectables while a patient is in the hospital. Oftentimes, outpatient providers will follow whatever inpatient does. A patient has had an episode. They've gotten to the point where they need hospitalization. If we can initiate these in the hospital, outpatient providers will typically follow that. Where we have a barrier is ensuring patients actually show up for their next injections. Let's say we initiate something that's a monthly injection, we discharge them, and they should have an appointment in a month. What we have found is only about a third of our patients are showing up for that next injection. What we have found is many of the clinics where they are supposed to go actually don't even administer these injections.
Key Takeaways
- A convergence of prior authorization requirements, benefit classification shifts, rural injection site shortages, and fragmented EHRs creates compounding barriers that prevent patients with schizophrenia from consistently accessing and adhering to LAI antipsychotics.
- Pharmacists embedded in mental health care teams can serve as critical bridges across prescribers, payers, and care sites, catching medication errors, managing LAI transitions, and providing the holistic medication oversight that siloed systems routinely miss.
- Meaningful progress in schizophrenia pharmacotherapy will require Medicare provider status for pharmacists, sustainable reimbursement for coordination and injection services, and a national LAI registry to prevent dangerous duplicate dosing across disconnected care settings.
Many mental health clinics, especially in rural areas, are not large community mental health centers. They are small private practices or very small mental health clinics, but they don't administer these medications. It's up to the patient or their family to find an alternative place for patients to go. That's a real gap, and it leads to patients missing their injections. These are really beneficial medicines. They've been shown to decrease rehospitalization and improve long-term outcomes, but we've got to keep patients on them. That's really the key—persistence, particularly in transitions of care. If a patient's coming in from an outpatient clinic and they're on one, or we're transitioning over, there really is not a week that goes by that I don't get involved in a long-acting injectable at some level.
Pharmacy Times: What misconceptions or logistical hurdles continue to limit broader adoption of LAIs among providers, patients, or health systems?
McGuire: Yeah, I think we in the US continue to use LAIs far below the rates in Europe. I think there still are misconceptions and a lot of stigma in our society about schizophrenia. There are misconceptions about coercion, punishment, force, those kinds of things, even though we do have to do that at some point. Those can be misconceptions. Another hurdle that can limit utilization is that there are some hospitals that may not stock these long-acting injectables, and they're expensive. They are worth their cost to an insurance plan because they can help keep patients out of the hospital and improve their long-term outcomes, but on a pharmacy budget in a hospital, that's a huge hit.
Now, a lot of manufacturers provide free product to a hospital to allow hospital initiation, but there are many hospitals where it's against their policy to take those products, so that presents a barrier for those patients to get those LAIs in the hospital. A lot of outpatient clinics think it should be the hospitals that do these. Some hospitals think it should be outpatient clinics. So there's kind of a disconnect there. Again, injection-site availability is a major logistical hurdle that we have to address. As I mentioned, there are many patients in rural areas, and they may not have good access to somewhere to go get an LAI. If we could have more injection sites, more pharmacists, and more pharmacies administering these, they could really help a patient population that needs our support.
Pharmacy Times: The mental health care system is often described as fragmented—where do you see the biggest breakdowns, and how do they impact continuity of care for patients with schizophrenia?
McGuire: It is definitely fragmented. There is not a week that goes by that I don't deal with this fragmentation. I practice at a freestanding behavioral health hospital. It's not part of a larger health system. So I have patients who come in from all over the community. They're referred by community mental health centers. They're brought in by Emergency Medical Services on transfer from an outside hospital. They're brought in by police, and they're brought in by family. We can't see records from other outpatient clinics. We don't know what their plan was at their outpatient mental health provider, specifically regarding LAIs. Assuming the patient has an address, I can usually pull from a database and see outpatient medication refills, and often a long-acting injectable will show if a pharmacy has filled it. That may tell me they're on a long-acting injectable, but it doesn't tell me the last time they got it administered. It may tell me the last time the pharmacy filled it.
I was just dealing with this earlier this week. I called the pharmacy. They verified the last time the pharmacy filled it, but they don't administer it at that clinic. Then I called the clinic to find out the last time the patient got it, and they told me the last time they had administered it. If the patient does not have an address, nothing imports in. A patient very well may have an LAI in their system, and I have no way of knowing that. That can lead to all kinds of medication errors. We may see somebody and say, “Oh, this would be a great candidate for a long-acting injectable antipsychotic,” and so we initiate that. Little did we know that just a few weeks before, they were at another hospital and got a long-acting injectable there. Now they've either been doubled up or received 2 different ones. This fragmentation really is difficult for us as mental health providers to maintain persistence. As I mentioned, a lot of our patients that we initiate on LAIs are not transitioning for their next appointment. That could be for any number of reasons. The discharge summary didn't get there. The outpatient clinic can't see our records. So do they know the exact date the patient got the medication?
Pharmacy Times: From your perspective, what unique role can pharmacists play in improving care coordination and outcomes for patients with schizophrenia?
McGuire: If I had my wish, I would wish that every mental health team had a pharmacist who was part of that team, and every patient who was suffering from a mental illness had access to a psychiatric pharmacist. I think the role we can play is really critical for improving care for patients. As I've said, I get involved in long-acting injectables as well as other complex regimens all the time. I'm constantly consulted on choosing the right medicine, dosing it correctly, finding out the last time they got an LAI, whether they had ever been on an LAI before, and ensuring that we can transition them out to their clinic. We can really serve as a go-between among prescribers, payers, care sites, and pharmacists. Pharmacists often are the only providers who are looking at a patient holistically. We oftentimes get so siloed, but one of the values that a pharmacist can bring is that we do look comprehensively at a patient's medications.
I just caught an error yesterday with some major cardiac medications that were left off of a patient's regimen when they were admitted into the hospital. The medication reconciliation was done incorrectly, and medications that could have had a dire consequence were left off. Having a pharmacist as part of that team can help ensure that those gaps are closed, ensure smooth transitions, and really serve as a bridge there.
Pharmacy Times: Looking ahead, what changes—whether in policy, practice models, or care delivery—are most needed to better integrate pharmacists into the schizophrenia treatment landscape?
McGuire: I think there needs to be better reimbursement. Pharmacists are not providers under Medicare, and that continues to hamper our ability to get reimbursed for services that we provide. Expanding pharmacist involvement in these transitions of care could be really beneficial, but getting reimbursement for it is a problem. Greater integration of pharmacists into mental health care teams and having pharmacists as mental health providers in mental health clinics could help, but again, reimbursement is a barrier there. Until we get broad recognition of pharmacists as providers and can identify reimbursement pathways, I think we're limited in what we can do. I experience that myself. I mentioned I have an outpatient clinic, and I do some billing for it, but it's not an easy process because we have that provider barrier under Medicare.
If there was some way to get electronic health record (EHR) integration, that would be amazing. Even if it was something as simple as the controlled substance reports that so many states have that pharmacists can check to see controlled substance prescribing, if there was some kind of registry for long-acting injectables, that could help prevent medication errors and improve adherence. I also think pharmacist administration of long-acting injectables could really improve care for patients. There are some pharmacies that are administering injectable medications, but it's not broad, and there's not good reimbursement for it. Again, there's not a great pathway for pharmacists to get paid for that service.
If we send a prescription for a long-acting injectable to a pharmacy, most of the time the patient has to go to the pharmacy, pick it up, and then go somewhere else to get it injected. If that's not their mental health clinic, they may have to go to yet another location. Potentially, they have 3 different places that they're going: one to get their medication, one to get it administered, and one to see their mental health provider. If the pharmacy was administering it, that could potentially cut out one of those.
