There was a time when decisions about patient care were made by the physician and the patient. Nowadays, insurance companies are forcing physicians and patients to rethink those decisions.
That’s not always a bad thing. I was very relieved when one patient called to say that Armour thyroid (which was prescribed by his previous physician) was no longer going to be covered by his plan, so I had to switch him to levothyroxine. This is what I wanted to do anyway. I have had a patient say that a thyroid I 123 uptake and scan (ordered by their primary-care physician) would not be covered because they did not have hyperthyroidism, to which I replied, "Good, cause you don’t need it."
But many, many times, it is just intrusive. And other times, it is just a waste of time and money. Oh, you can spend the time fighting them, getting prior authorizations, writing letters of medical necessity; or you can take the easy way out and do what they say.
I know of some doctors who will only write for generic drugs. Don’t get me wrong. I have nothing against generic meds. If there is an available generic drug that is effective and safe, then by all means, it should be used. But take diabetes for example. It is such a complex and progressive disease, and many people need combinations of drugs to treat it. So when you have exhausted your generic choices, what do you do? There are some physicians who stop there. Why? Because it requires too many manhours to get approval for a drug in a newer class or to give the patient information about savings programs or patient assistance.
I had one patient who was on insulin and wanted to go on an insulin pump. It was denied by his plan, but they said his doctor could write a letter of medical necessity. He was allegedly told, “It’s probably going to get denied again anyway” and the letter was never written.
I particularly despise this time of year, when all the plans have renegotiated with pharma and have changed their formularies. Patients stable on their meds need to change to another brand. I used to fight every fight. Tried to get prior authorizations (PAs) for everything. Now I pick my battles. So long as the patient is okay with it and the alternative drug is comparable, I will switch them. I have one patient who each January has had to change her pill from one brand to another, and back to the original one. Fortunately, she does equally well on all three. But sometimes the formulary alternative is not acceptable, to me or the patient, in which case the phone calls and paperwork ensue.
I long for the days when I could write a prescription for a drug that I felt was most appropriate for a particular patient, or for a test that I believed to be important without having to justify it to someone without a medical background. And for goodness sake, can the insurance companies or prescription plans make sure the people who are taking our PA call can pronounce the medications or words like “testosterone” and “neoplasia," that way I can somewhat less frustrated about having to defend my decisions to this person with the checklist? Ah, I suppose that’s a whole separate rant.