Insurance Practices: This Insanity Must Stop

May 20, 2011

By now, insured Americans are familiar with the routine “cost-saving” measures created and implemented by insurance companies. What is probably not known to most people, however, are the routine oversight procedures that intrude on patient care, aggravate “providers,” and consume untold amounts of time.

By now, insured Americans are familiar with the routine “cost-saving” measures created and implemented by insurance companies. Examples include different copayment schedules and reimbursement rates depending on physician network status; designated contracted facilities; medication choices; significant surcharges for brand-name medications over generics; and pre-approval for a range of procedures (eg, colonoscopies and MRIs). Such intrusions into patient care have become so routine that they are now the normal experience for patients and physicians alike.

What is probably not known to most people, however, are other, routine oversight procedures that intrude on patient care, aggravate “providers,” and consume untold amounts of time-presumably in the service of controlling health care expenses. The following examples illustrate “cost-containment machinery” out of control.

Vignette 1: A patient of mine requests a new prescription for her antidepressant, Venlafaxine, a popular, generic form of the brand-name drug Effexor. This medication is available in several strengths: 37.5 mg, 75 mg, and 150 mg. Over time, balancing effectiveness and side effects, my patient and I had arrived at an optimal dose for her of 112.5 mg per day, so I wrote a month’s prescription for 90, 37.5-mg tablets and thought no further of this routine matter-that is, until her pharmacy called to say that the patient’s insurance company had refused to authorize the prescription until they received a call from the physician.

As most doctors will recognize, such requests presage time-consuming ordeals: assuming one has the insurance information on file (insured I.D., carrier contact information) and doesn’t first have to place additional calls to the patient or pharmacy to get this, the call to the insurer predictably entails long delays, automated menu choices (which must be listened to lest one make a wrong selection and be sent to the wrong department, necessitating starting over), and, eventually, the opportunity to speak to an administrative screener, who may or may not be able to provide the reason for the requested call. If the caller is fortunate, the call is passed on to a pharmacy assistant, who vets the call for the pharmacist, explains the reason for the denial of coverage, and then connects the caller to the pharmacist who is the only one empowered to resolve the matter.

Each of these conversations includes asking the physician/caller to identify him/herself, confirming name, address, telephone number, and various physician credential numbers, as well as restating the entire premise of the call.

In this particular instance, the explanation for denial was the following: The patient’s plan would only cover a maximum of 60 pills of 1 dosage of a medication for a 30-day period. They insisted that I write 2 prescriptions-1 for 30 tablets of 75 mg and another for 30 tablets of 37.5 mg-in order to provide 112.5 mg in total!

As any health care professional knows, treatment compliance is always a major issue and facilitated by the simplicity of a treatment regimen. Using 2 prescriptions that involve different strength tablets when only 1 size pill could be provided constitutes poor care and only serves some contracted financial restriction. In this instance, I was able to convince the pharmacist to authorize 90 tablets of the 1 strength-but only for 1 year, at which time I would have to repeat the process and re-authorize the deviation from contracted coverage. The entire call, which I placed with my patient present, lasted 25 aggravating minutes and demonstrated for her the previously unrealized influence of her insurance plan on the care she receives.

Vignette 2: Similar to the previous scenario, a pharmacy called me after being denied coverage for a patient’s monthly prescription of 30 antidepressant tablets. After the customary, time-consuming, repetitive screening process, the explanation for the denial was that, without a call from a physician documenting clinical need, the patient’s insurance only allowed her to receive 21 tablets in any 30-day period!

Pharmacologic treatment for depression requires daily antidepressant medication, not alternate days or 7-out-of 10-day dosing. Requiring physicians to plead on behalf of their patients to receive a daily allotment of medication is absurd. As in the first example, I was able to obtain an override of the patient’s nonsensical contractual limitation, but again this was a lengthy, unnecessary intrusion into a patient’s care. This individual, himself a business owner and the payer of the premiums, also overheard the entire conversation with the insurer and was aghast and horrified at the interference passed off as cost oversight.

One can only imagine what this massive bureaucratic machinery costs the insurance companies, and, by extension, the patients and the employers who pay premiums. Savings achieved through the hassling of physicians and the implementation of ridiculous limitations cannot be achieved without compromising the quality of care so provided-in the first instance, adherence to the policies would have threatened compliance or led to prescribing a different dose than the clinically optimal one. In the second scenario, adherence to policies would have meant inadequate treatment and exposing the patient to a significant risk of relapse.

Many physicians and institutions have dealt with these oversight problems by hiring dedicated staff to deal with these matters. Most solo practitioners, like me, cannot consider this alternative-but even if affordable, such a solution seems to legitimize the absurdity of the problem. If health care reform-not health care compromise-is to evolve, this bureaucratic insanity must be addressed. Perhaps greater transparency to patients and employers of exactly what they are purchasing with their insurance premiums might be a worthwhile first step.