The Wall Street Journal had an interesting article the other day entitled Waging Health Battles by Fax written by Dr. Benjamin Brewer. Here are the key graphs:
My patient needed his arthritis medication.
The local pharmacy couldn't get approval from his insurance company to fill my prescription for the painkiller Celebrex. They faxed me a form on which to make my case for the drug.
Completing the detailed form is my penance for trying to give a $120-per-month Celebrex prescription instead of a $4 generic. I support treating patients according to the best scientific evidence, including using standardized protocols that can improve quality and often reduce costs. But I've been this man's doctor for 11 years, and I know his medical needs. Over-the-counter acetaminophen and other arthritis products haven't helped him.
Still, his insurer thinks it knows better. And the company puts the burden on me to prove the necessity of my medication choice. The judge is someone who doesn't know my patient's history and who isn't a doctor.
The local pharmacies used to help us with these requests, but they have given up. The overhead burden was too great. There is a battle that goes on behind the walls of the family doctor's office every day. We try to get the medications and tests and referrals that our patients need while also seeing patients who require care. The insurance companies don't mind me taking heat from the patients when they don't get the medication I recommend. And they don't have to worry about the liability that I, as a doctor, face for using cheaper drugs that may put the patient at higher risk of complications.
They want me to incur the overhead and frustration that comes with trying to prove to a non-doctor that I know my patient and what I'm talking about. They want to cut costs, and they don't really care about how it affects my patients or my practice. If they make the process hard enough, they hope I'll just give up. There is even a term in the managed care literature for that kind of deterrence: the "sentinel effect."
A 2001 study showed that a doctor seeing 22 patients a day, averaged one insurance hassle lasting for every four or five patients. More than 40% of hassles were reported as interfering with quality of care, the doctor-patient relationship, or both.
I think the hassle factor has doubled in my practice since 2001. Most patients are minimally aware of the battles we fight daily on their behalf. They wonder why the office gets bogged down or why doctors or office staff don't call back. Sometimes I make it through all the hoops to get patients what they need. Sometimes I don't. I failed to convince a patient's insurance company to approve a stronger, brand-name cholesterol medication, because her triglycerides had remained uncontrolled on a generic medication for only five months, not six.
Next month I'll probably be able to get her what she needed in the first place, but my staff and I will be forced to do all the same paperwork again. Against the rising tide of paperwork, my office had to see 28 patients the day my Celebrex prescription was denied.
Dr. Brewer is spot on. We end up fielding about 2-3 requests per day for the denial of the optimum medication for patients in favor of cheaper generic medications. Oft times, the generics are not the therapeutic equivalents of the drug that was originally prescribed, and sometimes it happens that patients will be well controlled on their current regimen and then suddenly, coverage is denied, and they are forced to take a generic.
The worst problem is the substitution of a non-equivalent generic drug increases the patient's disease burden.
Thus every minute that the patient has suboptimal control of a treated parameter, the end organs affected by the lack of control are adversely affected. Who will bear the responsibility for this? In the end it is the patient who suffers, and the physician who bears the responsibility for rolling over and compromising his best medical judgment to save money for an insurance company.
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