Once upon a time, in a little town called Mayberry, all things were good. No one really became ill, but if he did, the local town doctor would prescribe a medicine that was promptly filled by the “Ma & Pa” Pharmacy. The patient got better because of the doctor’s expertise and the prompt response of the pharmacy to deliver the prescribed medicine to the ailing individual.
If “Mayberry” ever really existed, it certainly does not today. How many times have you been to the doctor for an ailment and the medicine prescribed by that trained and licensed practitioner was denied by your insurance company once you took that prescription to the pharmacy? Two, three, maybe even 7 days later, after much haggling with the insurance company, you finally get your medication. Or, when you pick up your prescription from the pharmacy, after doing a little shopping to occupy your time while the prescription is being filled, the pharmacy technician notifies you that your insurance company would not cover the prescribed medication, switching it instead for a cheaper version (not even generic version of the same drug)! Believe it or not, sometimes the patient is not even notified of the switch! And this is acceptable practice?!?
What Role Does Your Health Insurer Play?
In April of 2010, Maryland MedChi, the Maryland State Medical Society sponsored a survey for its members titled, “Impact of Patient Health Insurance Protocols on the Maryland Physician’s Ability to Provide Care.” This survey assessed the distribution of perceived problems across the state of Maryland and the impact of insurer protocols on patient care, physician practice management and physician professional satisfaction. An essentially universal frustration amongst respondents (95%) was the negative impact of insurance carrier requirements on regarding what physicians can prescribe or order on behalf of their patients. Depending on the insurer, there were pre-approval protocols, step-therapy protocols, therapeutic switching and others that significantly affected the physician’s ability to treat his or her patient. The problems related to time spent “haggling” with the insurer, communicating with patients to explain the problems, researching potential interactions with other medications or patient conditions, determining other similar failed therapies in an attempt to justify the prescribed therapy, and others. There are even instances when a patient presents to the hospital for admission to a Hospitalist, and the physician’s office sends the patient’s current medication list to corroborate current therapies only to find differences between the patient’s medication bottles and the current list due to therapeutic switching by the insurance company. Another even more potentially problematic perception of the physician respondents (59.5%) involved arbitrary delays or outright denials of prescribed therapies by the insurers.
What’s the Motive?
So, you ask what the basis is for this and how do the insurers get away with such mandates? It all boils down to money. Typically businessmen run insurance companies, and these businessmen are making business decisions without any inkling of understanding of medicine or seeing an actual patient. Medical News Today recently reported a survey performed by Global Healthy Living Foundation, a non-profit patient advocacy group, that corroborates the Maryland MedChi findings: ”…up to 70 percent of prescription medications are changed by health insurers, denying patients the drugs their doctors prescribed” because the substituted drug is actually cheaper. This survey has identified serious sequellae to this business practice such as adverse reactions, poor recovery rates and worsening of chronic conditions.
The trickle-down-effect of these business practices, in addition to the physical effects on the patient, involve basic economics. Physician practices have to spend more time in communication with the insurer, the patient and the pharmacy trying to address the problem, taking time away from patient care with n0 compensation (up to 60 hours a week in some practices according to the Maryland MedChi survey). Some busier practices have had to hire experienced medical professionals (up to $75,000/year salary) simply to intervene with the insurers for pre-approvals and authorizations. Additionally, patient adverse outcomes and/or worsening of chronic conditions often lead to hospitalizations, time off work, and even job loss. This seriously affects work production, family income, and in some cases, can lead to permanent disablility placing additional strain on the already over-burdened Medicare/Medicaid system.
How Did this Happen in the First Place?
My question is, how did businessmen get into the practice of prescribing medications? After all, physicians have spent 4 years in undergraduate programs, 4 years in medical school, and 3+ years in residency and sometimes 1+ years in fellowships to learn medicine and pharmacologic interventions. These businessmen have perhaps spent 4 years as business majors (not a lick of medicine) and maybe 2 years in a Masters of Business program (still no medicine) in order to dictate what medications an ill patient is taking?! So, when did these businessmen get their degree to prescribe? Essentially, that is what they are doing! And for all of our kicking and screaming, it is still going on in 49 states and the District of Columbia.
The Louisiana “Purchase” Law
The state of Louisiana has led the way in fighting this trend; they passed legislation last year prohibiting the insurance companies from switching medications once they are prescribed. Currently, New York, California and Missouri have legislation pending that would prohibit this practice, as well. More states need to advocate for their citizens with regard to such practices; it would also help the physicians and other mid-level providers who prescribe medications provide effective patient care. The anticipated physician shortage (124,000 less providers nationally by 2025) can only worsen as physicians threaten to retire early, sell their practice or move to other more physician-friendly states (not to mention the move to “boutique medical practices” that would bypass insurers completely) due to dissatisfaction with the profession. The general public needs to be calling, emailing or writing letters to their legislators to advocate for these changes! ”Mayberry” may never exist, but we can make the system better for everyone.
What’s your story? Has this happened to you or someone you know? What can be done about this?