HEALTH INSURANCE COMPANIES PRACTICE MEDICINE AND PHYSICIANS PRACTICE HEALTH INSURANCE REGULATIONS

Dr. Do Good opened the door of the examination room after answering an obviously unpleasant phone call. He was visibly upset, and I wanted to find out what he was miffed about. I asked, “Doctor is everything okay?” He responded, “Mr Brown, I am getting sick, tired, and fed up with these health insurance companies. I went through medical school and a residency program to acquire the necessary skills and knowledge to help people. I have not written any frivolous prescription and when my patients are stabilized on a medication, I leave them on that medication. Remember how we struggled to control your blood pressure on Hyperterol. Now Uncover Health Insurance has removed Hyperterol from their formulary and replaced it with Bepaterol. For you to get Hyperterol, I must try you on Bepaterol. Do you recall how you almost had a heart attack on Bepaterol before you were switched to Hyperterol. For you to get Hyperterol which you been taking for 5 years, I must go through a prior authorization process. Hyperterol was on their formulary when you enrolled with them and that was why you chose Uncover. Summarizing, I may prescribe any medication, but the insurance company decides what the patient gets. The health insurance companies practice medicine and doctors practice health insurance regulations.”

Mr. Brown asks, “Is it a doctor at the insurance company denying the prescription.
Do lawyers, accountants, engineers, and pilots have a similar prior authorization process before taking actions on behalf of their clients?”

“Are you kidding me, Mr. Brown. No, the person at the insurance company end is a pharmacy technician or a new hire with a high school diploma reading off a list of questions from a manual. It would have been better if I was talking to a health professional. The technician or high school graduate subsequently puts me through to a real pharmacist and I must go through the grill again. I wish that airline pilots would have to call ground control before banking right to avoid a head on collision with another aircraft.”

That will be cool,” replies Mr. Brown derisively.

One may wonder how America medicine descended to this low, where doctors are no longer in the driver’s seat of medicine but are being driven by businesspeople. The origins of the problem will be discussed in future posts. A health insurance company that you chose because it covered your medication can stop covering your medication on a whim. Your health insurance company will switch you without notice to a similar generic drug marketed by another company because of a 0.01 cent advantage per prescription compared to your current medication. Benevolent companies may offer you a 30-day supply of your current prescription while you mull over your choices.

Your choices are
1. Go along with the new prescription which may have adverse effects on you.
2. Have your busy doctor fight the insurance company to get your medication pre-authorized.
3. Pay for your current medication out of pocket. Out of pocket means paying for something that your health insurance company ought to cover with your own real money.
4. Wait for the new open enrollment period which may be months away.

There really should be a law mandating that no health insurance company can deny coverage for a medication that was on its formulary list when you enrolled in its plan until the next open enrollment period. This will take care of some of the mess but not all, but we must start from somewhere. More to follow.