Sunday, March 08, 2009

The Minneapolis...Or Is It Hartford?...Two-Step

Conjure yourself as a wallflower: You are a shy early-adolescent compelled by your parents (who at all times adhere to the operative cultural norms) to attend your first dance.  You would rather not be there at all.  Your life as it was was perfectly acceptable.  You were happy with the old, self-sufficient ways.  But now, along with your peers, you are entering a new phase.  From now on the world will work dyadically.  More and more, you will be required to operate in conjunction with a second party.  And this second party, in many respects, is not sympatico. Its motives and methods and  do not always align with yours.  Yet still you hope for the best...

Bring up the music, turn down the lights - the moment has arrived.  Your expectations are shaped by what you believe you are owed: a polite and respectful pairing; civility, if nothing else.  Instead you are greeted with a rude awakening.  Your partner is an arrogant lummox, indifferent to your sensibilities. While the band plays waltz music you are dragged through a lumbering bump-and-grind.  In the process your hair is mussed, one foot is mashed,  an earring is dislodged. What's worse: at the end, there's no apology, no acknowledgement of the brutishness of what has just transpired; indeed, you are quite convinced that you are not alone - you are merely the first of many hapless victims for that evening alone.

Welcome to the rhythms of "step therapy," yet another barbed arrow in the quiver of managed care, still seemingly in ascendency, a galling procedure whereby "prior authorization" for a prescriber's first choice of medication is "denied" until such time as (usually two) "preferred alternatives" from an insurance company's formulary have been tried and have proven either ineffective or intolerable.  I had thought it insult enough that patients be required to "fail" two trials of medications with inferior clinical profiles (e.g., adolescents in my psychiatric practice are now "required" to try two generic stimulants whose short or intermediate duration of action is guaranteed to leave them without any therapeutic benefit during the second half of the school day - unless, that is, they wish to submit to the stigma of presenting to the school nurse every day for their "stupid pill" - before they can receive the long-acting medication that is the standard of care recommended by the American Academy of Child and Adolescent Psychiatry) before gaining access to what, from the beginning, simple common sense held to be the proper choice.  Despite years of steeling myself to callousness of the managed care organizations, I was nonetheless appalled by my most recent encounter with step therapy requirements, since the process has been rendered EVEN MORE LUDICROUS by the inventive touches of faceless executives bent on achieving promotion, I would wager, through demonstrations of their ability to concoct ever more sociopathic obstructionistic schemes. Consider this excerpt: A new patient presents to my practice, having moved to Rhode Island from a different state.  For a year or more, she has been taking Strattera, with good results, for her ADHD, having experienced adverse effects from previous trials of methylphenidate and mixed amphetamine salt preparations.  In conjunction with her move, however, her health insurance has changed. When the first prescription for Strattera reimbursable under the new plan is presented to a Rhode Island pharmacy, a prior authorization form is faxed to us by the insurer.  The PA asks for documentation of failures on two formulary drugs, a condition which the patient's clinical history does satisfy.  My office submits the PA form, properly executed.  Several days later, we receive notification that the PA request has been denied, because, in the standard boilerplate, the Strattera is not "medically necessary."  I then instruct my office manager, as I do quite frequently these days, to request a "peer to peer" review in appeal of the decision.  More time passes.  Finally, I am called by a retired (probably on the basis of "burn-out," if he has had many such experiences as I am relating) psychiatrist NOW EMPLOYED BY THE INSURER (no conflict of interest there!).  After a little perfunctory back-and-forth, he informs me that the denial will have to stand because, as I have failed to note in the fine print, treatment failure with the formulary alternatives did not occur IN THE LAST SIX MONTHS.  My efforts to cajole him into a different opinion through the use of logic fail.  His decision is firm.  In essence, I am told: IT DOESN'T MATTER THAT THE FORMULARY PRODUCTS WERE ALREADY TRIED AND PRODUCED ADVERSE EFFECTS.  IF YOU WANT THIS PATIENT TO RECEIVE REIMBURSEMENT FOR STRATTERA UNDER OUR PLAN, WE WILL REQUIRE YOU TO AGAIN GIVE THE PATIENT MEDICATIONS WHICH, AS THE PATIENT HAS TOLD YOU, PRODUCED ADVERSE EFFECTS.  End of conversation.  Click.
Expletive deleted.

How will the story end?  Happily, I predict.  The reason being that I will prescribe one tablet of Ritalin to the patient and, then, one tablet of Adderall.  The patient will be instructed to fill each prescription in sequence, and then flush each tablet down the toilet.  The insurer's preconditions will thus be satisfied and the patient will be able to use their insurance benefit.

At least two lessons, it seems to me, can be derived from this anecdote.  Number one: the chaperones have failed at their task.  Which is to say, WHERE ARE THE INSURANCE REGULATORS?  How can this kind of grossly manipulative, illogical protocol be allowed to exist?  And sadly, number two: PLAYING THE SAME KIND OF MENDACIOUS LITTLE GAMES THAT THE INSURANCE COMPANIES PLAY OFTEN IS THE ONLY ETHICAL COURSE OF ACTION.  And so it goes - two-stepping with the Leviathan.


Anonymous said...

I don't want no 'government bureaucrat' telling me what medicines I can and cannot have. On the other hand, an insurance bureaucrat, doing the same sort of policing, is a-okay in my book--after all, we KNOW how well the free market works, how effective self-regulation is, and that my paid-for insurer ALWAYS considers my health and well-being above everything.

(sarcasm intended)


MedInformaticsMD said...

I imagine there are other docs who will simply comply. Somewhere a patient takes med that caused adverse effects two years prior, this time goes into cardiopulmonary arrest and dies.

Doctor gets sued, insurer says they did not prescribe the drugs, merely refused to pay for the expensive one.

Does the term "Russian Roulette" come to mind?

-- SS

Nancy Frugé said...

Dr. Denby calls to our attention health care insurance plan rules that bar physicians from prescribing appropriate tests and treatments to their patients. Such rules serve to protect the interests of health care insurers rather than patients. Physicians’ prescriptions of appropriate tests and treatments not only provide relief for patients and prevent further problems, but also reduce health care costs.

What can we do to change health care insurance rules that are detrimental to patients?

Gentilello et al. demonstrated to stakeholders that prescribing appropriate tests and treatments to trauma patients with alcohol-related disorders reduced health care costs. [1] Dr. Gentilello has been instrumental in changing health care insurance rules that interfered with appropriate medical care. [2]

As Dr. Denby points out, much more work needs to be done in this area.

[1] Gentilello LM, Ebel BE, Wickizer TM, Salkever DS, Rivara FP. Alcohol interventions for trauma patients treated in emergency departments and hospitals: A cost benefit analysis. Annals of Surgery. 2005; 241:541–550. [PubMed]
[2] Join Together. Alcohol-related insurance denials in trauma centers are common, study says. October 28, 2005:

Anonymous said...

If the pt is in a "self-insured" plan, there is little to no recourse in state law, as self-insured plans fall under the federal ERISA laws.(UHC, BCBS, whoever are just "administrators" - they take care of the delays and denials.)

Nancy Frugé said...

Anonymous, thank you for bringing up this point. I support changes in rules—at any level—which remove barriers to physicians’ prescribing appropriate tests and treatments to their patients.

At the state level fifteen states have signed into law a measure that removes the Uniform Policy Provision Law (UPPL) from the state's insurance code. Before the UPPL was repealed in California, state law mandated that insurers "...shall not be liable for any loss sustained or contracted in consequence of the insured's being intoxicated...”

Physicians and others argue that "alcohol exclusion laws" like UPPL create barriers for the practice of evidence-based medical care.

The removal of UPPL from states’ insurance codes is advantageous to insurers: a) repeated insurance claims are avoided and b) better outcomes for patients reduce health care costs in the long term.

For the scenario presented by Dr. Denby, I believe we can find evidence in the scientific literature to support his reasoning that a patient who has experienced an adverse response to a medication is likely to experience the same adverse response again (as MedInformatics points out in this thread).

State laws still apply in cases regarding medical treatment. According to David L. Bacon, patients who are enrolled in HMOs under ERISA have a couple of options when claims are improperly denied. Look here:

Join Together will merge with The National Center on Addiction and Substance Abuse (CASA), Columbia University, May 1, 2009: