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As Insurance Companies Play Both Doctor and Pharmacist, Be Wary the Patient

What qualifies an insurance company to determine the effectiveness of a medication for a particular patient by one brand vs. another, brand vs. generic?
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Americans have always been proud that we have been worldwide leaders in innovative medical care. Our doctors are among the best trained physicians available. Yet, today physicians and medical clinicians seemingly must answer to a higher power: insurance companies. As an MD trained in child, adolescent and adult psychiatry, I shall only address this issue as it affects people with mental health coverage (which is generally quite limited if it exists at all), although many of my colleagues in other branches of medicine have sadly and irately conveyed similar scenarios to me.

Let me start with some cogent examples. The parent of one of my patients was told that the insurance company would only approve two pills of the same dose of a certain psychiatric medication daily. If the psychiatrist recommended three tablets per day the family could pay for the extra pill out of pocket or the doctor would have to call the insurance company to seek approval. This, of course, will require the family to pay more to get the proper prescription or take up unnecessary physician time, time that could be much better spent on patient care. When did the insurance company get to decide the proper number of pills and appropriate dosages of medication for patients? Who is answering to whom?

I've had pharmacists tell my patients that their insurance company does not cover certain medications in a class, but will approve others. This incorrectly assumes that all medications in the same grouping (used for the same problems) are equal. An over-the-counter medication example is to say that the following pain killers -- acetaminophen, aspirin and ibuprofen -- have the same effectiveness. An example of this with psychiatric medications would be covering one antidepressant but not another. Although both Prozac and Paxil are in the group of SSRIs, they are very different compounds and cannot be assumed to be equal in effectiveness.

What qualifies an insurance company to determine the effectiveness of a medication for a particular patient by one brand vs. another, brand vs. generic, or by any other comparison? Such is the role of the physician. When, and from where, did these companies get their licenses to practice medicine?

Routinely I receive letters from insurance companies telling me that the cost to the client (and in reality, the insurance company, too) of prescribing the brand name of a medication, is much higher than if I were to prescribe the generic and perhaps I should consider switching. That is hard not to find professionally offensive. I am aware when there is a generic available and should I have wished to have prescribed it, would have done so. First and foremost my concern is the overall health of my patients. In my practice there have been patients who have noticed definite differences (either mental and/or physical) with the generic brands of a few common psychiatric medications, and have asked to be placed back on the brand medications as they were more efficacious. Is it genuine concern that the patient will pay less for the generic or is it concern for their own bottom line that generates these letters? If the insurance companies were truly interested in saving their policy holders money they should stop playing doctor and taking up the real doctors' time by making us justify to them our prescribing and dosing decisions.

People may be surprised to learn that their doctor can be made to call a pharmaceutical arm of an insurance company to justify his or her writing of prescriptions for you. I've been questioned by employees who were neither doctors nor nurses; they had no medical background at all. It was very clear that the person questioning me was literally reading off a checklist drawn from a standardized diagnostic medical text and had minimal if any knowledge about the patient's illness. Yet this is the person who is supposed to determine if I'm prescribing the medication properly.

With most policies, the individual has to pay a certain amount out of pocket for each prescription, known as the co-payment. With some insurance companies, the amount of the patient's co-payment varies with different coverage levels, frequently called "tiers." For some, the generic form of the medication is tier 1 -- and therefore requires the smallest co-payment. Medications that are tier 2 may be brand name drugs thus requiring a larger co-payment. Tier 3 medications may be considered non-preferred medications, meaning the doctor writes "substitution permissible," but the patient prefers the brand and has it fills as such. This tier has an even higher co-payment. It's not infrequent that medications belonging to the same group are placed on different tiers. Of course the tier or level is set by the drug company. One suspects the cost per pill that the insurance company itself has to pay for the medication, plays a role in the cost to the consumer. Put another way, the more costly the medication for the insurance company, the higher the individual's co-payment.

Many companies have created a policy wherein the insured can get a 90 day supply of a medication by mail and have a smaller co-payment than if they bought a one month supply of the same prescription and had gotten it filled three times. This is a great benefit for someone who is on a medication of a precise dose with which there are no foreseeable problems or changes such as birth control pills. However when caring for mental health patients there are many factors present that one does not encounter in general medicine. Not prescribing more than a month supply when one is concerned about suicidality, disorganization resulting in the loss of pills, psychosis, or other important clinical issues makes sense. But what the insurance companies do is place the onus on the physician to determine if the patient should save money or should be penalized monetarily due to his tenuous mental state by only getting a one month supply of medication.

At one time it was said that people feared their doctors. Thankfully those days are long behind us. Now it seems more likely that consumers fear their insurance company. Increasingly doctors feel both compelled to answer to them and restricted by these impersonal corporations. Patients write larger premium checks and realize dramatically smaller benefits...just a lot more frills and fancy public service exposure, none of which benefits the policyholder. It is time for doctors and patients together to demand to know, "How and why do insurance companies make these seemingly arbitrary decisions which affect the health and checkbooks of millions of Americans?" Maybe once our questions are heard our healthcare system will start to have some answers.

"All decisions about prescription drugs are between you and your physician or other health care provider," boldly professes one insurance plan a patient recently showed to me. Am I the only person who is missing something here?