Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, December 22, 2006

Think About This

Topic: insurance companies whose preauthorization (or "prior authorization) process for approving medications requires a "trial" of one or more "equally effective alternatives" before the drug in question will be approved.

Example: I have a patient whose depression has been successfully controlled with name brand Prozac for several years now. (Yes, back when I was young and stupid -- about two years ago -- I offered her a trial of the generic; didn't work.) Now her insurance is again looking for a trial of cheaper meds.

Never mind that this patient is being asked to potentially suffer a relapse of debillitating depression symptomatology (or, as the esteemed Dr. Dork puts it: hosting the black dog.) What they are asking is for me to prove that their formulary medication choices are inferior to my selections based on clinical experience and the patient's proven response.

Not only are they practicing medicine; they are doing it badly.


At Fri Dec 22, 08:48:00 AM, Blogger Surgeon In My Dreams said...

Just found you! Enjoy what I've read so far. I look forward to a long relationship.

At Fri Dec 22, 09:07:00 AM, Blogger MedStudentGod (MSG) said...

What I've heard before is that there are physicians who aren't the greatest or struggled in practice or had a myriad of other problems that lead them to begin working for insurance companies. They are the ones dictating medical protocols despite their obvious lack of clinical experience. Or so I've heard.

But, the insurance company knows best. They've always got the patient's interests at hand no matter how absurd their actions may seem. Yeah, right.

At Fri Dec 22, 12:42:00 PM, Anonymous Anonymous said...

No, seriously, the generic will work JUST AS WELL. We, a group of over-paid insurance executives, swear it!

Pah. I love that I have insurance, hate the insurance company.

At Fri Dec 22, 01:20:00 PM, Blogger Sid Schwab said...

I have, on occasion, spent hours (seemed like it, anyway) on the phone trying to get authorization for an operation, usually starting with some clerk looking at a list of indications with no understanding of surgery. It's guilty until proven innocent with them. If one could wave a magic wand, there'd be a way to intentify docs who know what they are doing, who consider costs, yada yada, and leave them the hell alone. Of course, if I had a magic wand, the whole process would disappear.

At Fri Dec 22, 01:22:00 PM, Blogger Sid Schwab said...

1) I meant "identify."

4) I'm sure you already norticed.

At Fri Dec 22, 02:21:00 PM, Blogger Richard A Schoor MD FACS said...

Amazing. And if your patient has a terrible relapse and, well, you know, has "damages", because of the ERISA law, you, not the insurance company who is playing doctor, is potentially responsible/liable. Of course the carrier will say that all you had to do is ask us and we'd have approved it. Yeh, whatever.

I recently had a patient with a history of recurrent kidney stones who needed a follow-up CT scan. He was a helicopter pilot on a search and rescue coast guard chopper. The pre-cert wass denied 3 times (2 appeals), and it was not until I physically got on the phone and explained the dangers of flying a helicopter with a ureteral stone that they relented.
Thanks for the post.

At Fri Dec 22, 06:22:00 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

They are essentially dictating choice of medicine based solely on their formularies, which differ from plan to plan.

My most common fight is from plans who want my patient to use vaginal estogen creams rather than the ring or tablets, even when research has shown that systemic absorption (and theoretical exposure of the breast and uterine lining)is higher with the creams. Yet when I explain this to my patients, many still ask me to prescibe the cream because they cannot afford the alternatives.

At Fri Dec 22, 06:59:00 PM, Blogger outre said...

The amount of time that is wasted due to pre-auth stuff is unbelievable. I've gotten to a point of reading up on treatment protocols I might need in the future than seeing if I'll need to jump through hoops to get it.

I have more anxiety about having procedures covered than the actual thing. that isn't right...

At Sat Dec 23, 07:24:00 AM, Blogger Dr Dork said...


Your patient must suffer sufficiently to meet their actuarial criteria, to loosen the purse strings ?

I bet the insurance execs 75 yo Mom with recurrent depression doesn't have to jump through clinically dangerous hoops.

At Sat Dec 23, 08:06:00 AM, Anonymous Anonymous said...

I have also been going through this with some of my meds. Most recently was when they stopped covering one of my long term BP medications (Hyzaar)..They instead told my Doc I had to take "Lisinop-HCTZ"..

I developed the most aggrevating cough I ever had. Just a nasty non-stop dry cough. Not sick with a cold or anything else just a cough that wouldn't stop..It happened right about the time the baby was born. Not knowing for sure what was causing this bad cough I was really afraid to go to the special care nursery. Parents don't take to lightly to having a sick newborn and someone being in there coughing their head off.

My Doc said it was secondary to the lisinop-HCTZ. He had to call the ins. and finally once it was proved to them I couldn't take this med then they approved for me to go back on my Hyzaar.

Its getting scary when ins. companies second guess Drs. orders!

At Sat Dec 23, 09:52:00 PM, Blogger MedStudentGod (MSG) said...

What's scarier still is when doctors second guess themselves based on previous exposure to insurance demands.

At Wed Jan 24, 07:55:00 PM, Blogger Lynn Price said...

Nothing puts scabs on my eyeballs faster than an insurance company who knows better than my own doc and tells him I'm no longer allowed to take drug XYZ. Yeah, right, the guy who's known my medical history for a thousand years can't possibly know what's best for me. Phhht...deliver us from insurance companies.

I switched plans. The only thing those guys cover now is in case of surgery. I pay for everything else. Sure, it's expensive, but my blood pressure has never been lower.

At Mon May 26, 07:57:00 PM, Anonymous Anonymous said...

Try not to get discouraged with the took years to find the right combination to control my husband's episodes, and we're still struggling today. There are a lot of great non-traditional things to try down the line as well. I'll keep your family in my prayers. I know how hard it must be to see your girl struggling each day. Private Krankenversicherung

At Mon May 26, 07:59:00 PM, Anonymous Anonymous said...

Just found you! Enjoy what I've read so far. I look forward to a long relationship. Private Krankenversicherung


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