Who made health insurers God? My friend and I said the same thing the other day, "Insurance companies are running health care. And it's scary."
Increasingly health insurance companies are deciding what medicine we get regardless of what our doctors prescribe.
Last year my endocrinologist wrote a script for me for a new basal insulin, Toujeo. After a decade on Lantus, which daily petered out after only 19 hours, Toujeo's profile showed 24-36 hour coverage. Using Toujeo would mean I had insulin in my body, as necessary, 24/7.
But my health insurance company said "NO." To possibly override their refusal I had to jump through several hoops, including first use the two basal insulins on their formulary and prove they didn't work. Then have my endocrinologist get on her knees and beg they honor our request for Toujeo by submitting a second prior authorization form.
For six months during this process I got Toujeo on the down-low from a diabetes educator friend. And my blood sugars, and my life, improved.
Next punished patient
Fellow diabetes blogger, Mike Hoskins who's had type 1 diabetes thirty-two years, posted this on Facebook. It's a portion of the letter he received from his new insurance company denying his request for more sensors for his Continuous Glucose Monitor.
Permission granted by Mike Hoskins.
Mike wrote this along with his post, "Damn you, Blue Care Network...The reason there's no recurring pattern of Lows is BECAUSE of my CGM sensors. So, you want me to have dangerous hypos before you'll pay for the sensors I've been using already for 3 years?!?!
It's commonly accepted that, Continuous glucose monitoring provides maximal information about shifting blood glucose levels throughout the day and facilitates the making of optimal treatment decisions for the diabetic patient.
Mike's Facebook friends' comments of disgust and shared similar experiences are too numerous to list here. The reality - Hoskins is being denied the very instrument that allows him to take good care of his diabetes. The very device that may help him prevent diabetes complications in the future. Complications that will cost health insurance companies significantly more money than they're unwilling to spend now.
Mike followed up his insurance company's denial with a letter he titled, "I'd Rather Not Die Today." He told them the CGM has saved his life numerous times, that his in-range blood sugars doesn't mean he's "fixed" but that the technology is vital to his health and how ass-backwards their denial is. We shall see.
Health insurance companies restricting medicine, devices and procedures is not new. But it feels like it's happening with increasing speed and frequency. And it feels so blatant now; gone is the curtain behind which the regulators sit.
Punished patients numbers 3 and 4
A dozen years ago my friend Susan's endocrinologist advised that she get a CGM as her type 1 diabetes caused her to have frequent episodes of very low blood sugar overnight. By the way, that can kill you. Susan's insurer insisted because her A1C was under 7% (the range recommended for people with diabetes) she did not have diabetes.
Her insurer also told her that if she raised her A1C to 9% they would approve the CGM. Susan told her insurance company rep that if she indeed didn't have diabetes as they ruled, it would be very hard for her to raise her A1C to 9%!
Another friend with type 1 diabetes and hypoglycemia unawareness got an insulin pump and a CGM after giving her health insurance company a 14 day summary of her blood sugars, all blood sugars over an 8 week period, a graph of glucose trends over 8 weeks and a letter from her doctor of medical necessity as they requested. Then her insurance company denied paying for the necessary education to teach her how to use her devices.
And I know many, many, many, many, many, many, many, more stories.
Doing the wrong thing for the wrong reasons
What's on your health insurance company's formulary, not what medicine or device or procedure your doctor thinks you need, is increasingly determining what you get. Guess what, it will also determine your ability to be healthy.
It's transparent now that cost supersedes care. Shareholders and health insurance CEOs are being rewarded while patients are being punished. Every day executives at insurance companies choose higher profits and shareholder value over their members whom they say they protect.
What no one seems to be treating is the condition that's been created by insurance companies. By withholding drugs, devices, procedures and tests for conditions like pre-diabetes now we're creating worsening health for patients, and greater costs for insurance companies, over time.
This choice for short term cost reduction is a mistake. It is in shareholders' interest to give patients what they need now and reap greater return in the longer-term.
While our premiums go up each year and people are paying higher deductibles, health insurance CEOs are compensated in the multiple millions of dollars. Each of the CEOs from the top five health insurers took home (I can't say earned) at least $10 million. The CEO of Aetna, the third largest US health insurance company, was compensated $30.7 million in 2013.
Here's my message:
Patients - Don't roll over, write, document, fight
Doctors - Expect a fight, and please join us
CEOs, Board of Directors, State Insurance Commissioners and shareholders - Stop rewarding yourself at patient's expense. Do what's right.
President Obama - Condemn these ludicrous denials and get insurers instead to reward patients for positive health behaviors
And get out of our way. Stop punishing patients who educate themselves, take responsibility for their health and do so well that insurers don't even think they have an illness. Amen.
Riva is the recipient of the 2015 IDF Award for education and advocacy. She has written three books, Diabetes Dos & How-Tos, 50 Diabetes Myths That Can Ruin Your Life and the 50 Diabetes Truths That Can Save It and The ABCs Of Loving Yourself With Diabetes. Riva speaks to patients and health care providers about flourishing with diabetes. Visit her websites DiabetesStories.com and DiabetesbyDesign.com.