Don’t Call Me Provider

It has been quite some time since I’ve written on this blog. Lately though, one issue that has become increasingly troublesome is the use of the word “provider” as a blanket term to cover any professional who provides healthcare. I did not go to provider school, but rather medical school, followed by 4 years of psychiatric training before starting my own practice back in 1993. I am and will remain a doctor, NOT a provider. Recently, I spoke with a friend of mine who works as an attorney for an insurance company in their contracts department. She explained that insurers use the word provider in their language as a short cut. Ok, I can see that, but the problem runs so much deeper reducing the word count in a contract.

In her MommyDoc blog, Dr. Niran Al-Agba, a pediatrician in the state of Washington writes:

“Provider” was first utilized by The Third Reich, who embraced this moniker to degrade Jewish physicians as medical professionals. The historic root and use of the word “provider” deserves our attention and reflection because if we forget the tragic mistakes of history, we may be doomed to repeat them. While the more recent movement to disrespect the education and training of physicians was the brainchild of the federal government and corporatized medicine, this disdain for medical expertise has occurred before–to Jewish physicians living in Germany in 1937, before World War II. (https://peds-mommydoc.blogspot.com/2019/02/if-you-call-me-provider-i-will-assume.html)

In their article “Promoting Trust and Morale by Changing How the Word Provider Is Used,” JAMA. 2021;325(23):2343-2344 https://pubmed.ncbi.nlm.nih.gov/34047757/, John W. Beasley, MD1; Richard G. Roberts, MD, JD1; Allan H. Goroll, MD2 write:

Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. In 1965, Medicare began using provider for entities qualifying to receive Medicare reimbursement.1 Over the years, the use of the term has expanded to include an ever-enlarging set of individual health care professionals who qualify for payment, especially those in primary care, in addition to institutions (eg, hospitals, clinics, treatment centers) and third-party payers. As such, the term has become part of everyday language in health care delivery, for example, the popular use of the phrase primary care provider. While convenient and a source of pride for some, such use also poses risk for unintentional and potentially detrimental consequences.

I don’t equate insurance companies with Nazis, hate crimes, or the persecution of anyone considered “other.” Instead I aim to draw a line connecting the past and present and highlight the more sinister undertones of the term provider. As doctors we are being diluted and marginalized by the influx of less trained “providers.” Our field is being squeezed more and more by profit driven insurance companies, health care administration “systems,” hedge funds and private equity firms. If “provider” stands for any health care professional, where is the distinction?

Undoubtedly, there are many very competent nurse practitioners and physicians assistants. Physicians assistants, however, typically earn their title in 24-27 months. Even more worrisome is that some PA’s are pushing to be called physician associates, which would further blur the line defining roles. Nurse practitioners typically earn their masters degree in 2-3 years then sit for the APRN certification exam within a year. With at least 8 years of education and training, physicians are most often the best equipped to handle medical and surgical issues. It’s not a coincidence that PA’s work under a physician and often CRNP’s in some settings need a physician as a supervisor.

I am not implying that the other types of health care professionals are unnecessary or not important. Many times they are the first line of care or improve access to care. Otherwise closed practices can see more patients. Underserved areas see improved access to care. With the worsening shortage of physicians, many of whom are seeking early retirement if possible, this trend will continue. My focus, rather, is on the term provider.

If you look at a health care system’s entry on a Google search you’ll see a link for “find a provider.” It’s pervasive. Insurance company directories always use that term. Many times I have had patients complain that they went to see their doctor and instead had to see the PA or nurse practitioner. Sometimes this has occurred in the context of a lengthy doctor-patient relationship. It’s not right and ultimately it leads to more fragmented and often less than optimal care.

One organization that has done it right is Southern California Permanente Medical Group. Their Board of Directors passed a resolution in 2006 that prohibits the use of the word “provider” to describe physicians in our medical group.

The American Academy of Family Physicians (AAFP) published a position paper in 2018 stating the following:

The term ‘provider’ implies that the relationship between the patient and physician is a commercial transaction. The underlying premise of the ‘provider’ based environment is that health care delivery is essentially a market-based enterprise based on a market ethic. This contradicts the Academy’s position that the core of the family medicine specialty lies in ‘…the patient-physician relationship with the patient viewed in the context of the family.’ ”

Furthermore, our patients deserve to know who is treating them. Provider is such a non-specific and therefore meaningless term and contributes further to the decay of medical care. It’s one more assault on health care that contributes to the general sense of numbness and increasing depersonalization of direct patient care. As far back as 2012, Hans Duvefelt, MD wrote:

“Medical provider” is part of the Newspeak of America’s industrialized medical machine. It implies, as Hartzband and Groopman wrote in The New England Journal of Medicine, that: ” … care is fundamentally a prepackaged commodity on a shelf that is “provided” to the “consumer,” rather than something personalized and dynamic, crafted by skilled professionals and tailored to the individual patient.” (https://www.kevinmd.com/2012/04/implications-provider-doctor.html)

Nurse practitioners have their own unique approach and skill set. Physician assistants are not doctors but can diagnose and treat of people while working with a doctor. Physicians have the most training and education to understand, assess, diagnose and treat illness as well as to promote wellness and prevention. We as doctors need to stop accepting being called “providers.” Call us what we are. This mandate goes way beyond the degree we have earned. I’m concerned about the depersonalization of medical care as private (for-profit) insurers and the government have increasingly treated it as a commodity or an asset that they can mold and shape. For my part, I simply won’t answer to the term provider anymore. If asked if that is who (what) I am, I always answer, “no, I am the doctor.”

Inflammation, stress and depression

Many people intuitively understand that increased stress, either in the form of an acute trauma or more chronic stress, can contribute to or precipitate an episode of depression. Often, though, people think that they need to snap themselves out of it, just get through the stress and things will be fine. An appreciation of what stress does in the body and to the brain in particular goes a long way toward helping people understand the mechanisms behind it. Commonly, a depressive episode will occur in someone who already has a predisposition to depression. A family history of depression and/or past episodes of depression certainly increase one’s risk to become depressed. What may not be as widely understood is that stress causes inflammation in the body. Indeed, the immune system responds to stress by releasing chemicals known as cytokines (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3741070/), which can enter the brain by crossing the blood-brain barrier (https://en.wikipedia.org/wiki/Blood%E2%80%93brain_barrier). Cytokines involved include interferons, interleukins and tumor necrosis factor. These substances, which play a vital role in the function of a healthy immune system, can also activate specialized cells in the brain known as microglia. Microglia are located throughout the brain and spinal cord and account up to 15% of all cells found within the brain. They function as immune cells in the brain and are the first and main form of active immune defense in the central nervous system (CNS). When there is inflammation and these cells are activated, they release toxic substances that help to transmit the inflammation happening outside the brain to inside the brain. When that happens, these cells also begin to siphon niacin, a B vitamin that plays a role in cellular energy production, and tryptophan, the amino acid necessary to produce serotonin, which is thought to help regulate sleep, appetite and mood. (https://medlineplus.gov/ency/article/002332.htm) Instead of serotonin production, though, a different pathway is activated and the end result is an increased production of glutamate. Glutamate is one of the two main excitatory neurotransmitters in the brain, and therefore is essential for many of the bodies natural processes. (https://www.ncbi.nlm.nih.gov/books/NBK10807/) However, in excessive amounts, as often found either in chronic states of inflammation or after a closed head injury, it is toxic to brain cells and leads to cell death. Depleting the brain of the building block for serotonin can increase vulnerability to depression. Another consequence is the activation of prostaglandin E2 (PGE2), a principal mediator of inflammation in diseases such as rheumatoid arthritis and osteoarthritis. When PGE2 increases in the brain, the hypothalamus gland (https://www.endocrineweb.com/endocrinology/overview-hypothalamus) releases a hormone that then signals the pituitary gland (https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022786/) to release another hormone that tells the adrenal glands (https://www.endocrineweb.com/endocrinology/overview-adrenal-glands) to begin releasing cortisol. Cortisol (http://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress/art-20046037) is a steroid hormone that is often elevated during times of stress and when chronically elevated has been implicated in the development of depression as well as a host of other illnesses. Antidepressant medications, such as SSRI’s (Prozac is the prototype for this class) and SNRI’s (Effexor is the prototype for this class) can actually interfere with the entry into the brain of pro-inflammatory immune chemicals, so in addition to boosting brain levels of serotonin and/or norepinephrine, these medications may have an anti-inflammatory effect in the brain as well and therefore be neuroprotective. This narrative is shown graphically below:

We live in a world where general stress levels are increasing. Stress is a generic term, and it manifests in multiple ways. It can be the stress of chronic childhood trauma, such as sexual abuse. It a can be poor nutrition, poverty, limited access to good health care and living in polluted or overcrowded areas. It can be in the form of dealing with multiple losses, job stress, relationship stress or stress about the current political climate. The list is nearly endless. And certainly, one’s response to stress is often key. Some individuals seem to be more stress hardy, while other people seem to fall apart with the slightest of provocation. So how can we become more effective at managing stress when it is ever increasing? How can we adopt an anti-inflammatory approach to living our lives? Short of a radical departure from certain lifestyles, it seems inescapable, though I suspect that pursuing the fantasy of a much simpler lifestyle for many would bring about stresses of its own.

Let’s start with food. What we eat has become a large source of inflammation in our bodies. Processed food, fast food, food with a lot of added sugar and not the proper kind of fat, frequent consumption of grilled or charred-broiled food – all trigger inflammatory responses in the body. Chronic inflammation ultimately leads to illness, including an increased risk for depression. Changing one’s diet to eat more regularly at the lower end of the food chain, eating organic foods whenever possible (more recently this has become increasingly important with respect to wheat products (http://realfarmacy.com/reason-toxic-wheat/), and trying to avoid sugary and processed foods can be vitally important to lowering the overall burden of inflammation in the body and thereby leading to a healthier brain as well. According to Mark Hyman, MD, author of The Pegan Diet (https://www.goodreads.com/book/show/53915359-the-pegan-diet), food is information. People need to consider what information they are providing with the food they choose to eat.

Another important piece to diet is the impact food has on the microbiome. If the microbiome becomes imbalanced or unhealthy (dysbiosis), that can trigger the immune system to release cytokines, thereby raising inflammation levels in the body. Someone who has to take an antibiotic has most likely experienced the consequences of an unhappy microbiome, with the resulting diarrhea, abdominal cramping and other GI symptoms. If food is information, we need to consider how our microbiome is going to respond to it. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7589951/) Sometimes a good probiotic supplement can help. Readers should consult their doctors before taking anything.

Exercise is another way not only to stay in shape but also to reduce inflammation in the body. Practices such as meditation, Qi Gong, Tai Chi and martial arts can have an anti-inflammatory effect as can regular sexual activity and trying to maintain a balance between work and play. Psychotherapy and the possible use of psychotropic medication can also play a role in reducing inflammation in the body.

Sleep is also vitally important to overall health and in particular the prevention of inflammation. It’s well known that chronically disrupted or fragmented sleep leads to increased risks for cardiovascular disease (heart attack, stroke, high blood pressure), pulmonary hypertension (in untreated sleep apnea), diabetes, obesity, dementia and premature death. Sleep loss alters the mediators of inflammation (cytokines) (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3548567/), which contributes to the cascade of inflammatory chemicals in the brain as outlined earlier. Trying to maintain sleep hygiene, which means no screen time at night, avoiding caffeine (or making sure you consume none past noon), avoiding other stimulating activity at night, and sleeping in a dark and quiet room can go a long way to help establish healthier sleep rhythms.

Fighting inflammation in an increasingly stressed world is a complicated challenge to meet. With so many variables and so many choices, anyone can become easily overwhelmed and that can lead to inertia and hopelessness with a default to a person’s usual routines and habits. Pick one thing at a time to change and get comfortable with that before moving forward. Finding ways to stay grounded in one’s day each day can provide the anchor needed to maintain momentum and with it, the incentive to continue to change.

Extortion, MOC and the ABPN:

I received an e-mail with my “physician folio” report and a reminder that I would have to pay my $175 annual fee. It was my understanding, or, I guess, misunderstanding, that that was optional and that I could instead choose to pay for my next recertification exam in 10 years. I e-mailed the #ABPN (http://www.abpn.com/) and was told that previously, board certification was paid for at the time one applied for an exam. As of 2012, as part of the C-MOC program, the Board decided to change to an annual fee payment structure. Instead of a single fee at the time of the MOC examination, participants in the C-MOC program pay an annual fee. This fee covers Maintenance of Board Certification status, use of a personalized ABPN Physician Folios account with customized MOC tracker, and development and administrative costs of MOC examinations, including a 10% credit annually towards an MOC examination in a ten-year period. Maintaining board certification status does require satisfying the MOC requirements as well as payment of the annual fees. I was told, “when you apply for your next MOC exam, you will be able to apply the payments of the annual fees you have paid thus far to credit towards the cost of that MOC exam.” And by the way, diplomates certified before 2012, including lifetime certificate holders, may elect to participate in the program through their physician folios account. That means that they can simply continue on as they had been doing while the rest of us are punished because we recertified or were initially certified after 2012.

I responded that I may not choose to recertify again, as I will be 63 years old by that time and possibly retired. No statement was made regarding that, so I can only assume that the board then keeps all that money anyway for those nebulous “exam development and administrative costs.” And though I paid $1400 for the exam this time, I guess that that means that buried in the annual $175 fee over 10 years is that same $1400, though it is hard to imagine a greed driven board maintaining the exam at the same price in 10 years. But I figure, with all the psychiatrists required to do this now, that $175/year adds up to a nice small treasure that I am sure will more than adequately cover exam development and administrative costs while allowing the CEO to see an increase in his already >$800,000 year salary. Since I may not recertify at that time, I certainly don’t want the board sitting with any of my money to “save” it for the exam fee. I can keep track of my own credits and don’t need an ABPN-monitored physican folio to do it for me. The last I checked, the guidelines for maintaining certification are still published for free. This seems like just more ABPN needless bureaucracy and a way to generate more income for the ABPN, as there is no value in this for the ABPN diplomates. The ABPN website notes that with these physician folios “physicians can activate accounts that will enable them to keep their demographic and license information up to date, view and attest to their MOC activities, and apply and pay for examinations and annual MOC fees. Physicians must activate an ABPN Physician Folios account on the ABPN website to begin the MOC process and gain the benefits of the program.” What benefits? You mean that this is necessary and we simply cannot enter a payment portal on our own to pay for exams? We cannot send in an annual report attesting to our MOC activities? There has to be a “physician folio” that we have to finance with our ever dwindling dollars? Those so called “benefits” of paying an annual fee feel distinctly like self-aggrandizing rationalization for what amounts to extortion. Indeed, further down the same page, ABPN again explains/rationalizes the fee in a poor attempt to anesthetize us into a sense of “just business as usual” in much the same way various other organizations pull the proverbial wool over the eyes of their constituents. Just look out how enticing these “benefits” are:

There are several advantages C-MOC program participants gain:

  • Annual fee instead of a large fee at the time of application
  • Customized list of MOC activities that can be provided to employers, hospitals, licensing boards, etc.
  • Reminders from the ABPN regarding MOC requirements that are due to be completed
  • Easy-to-use system to track individual requirements
  • Personalized ABPN Physician Folios account.


I wrote again to express my concerns and was informed that indeed the MOC requirements and annual fee do need to be satisfied as long as a diplomate wishes to maintain certification. If after 3 years of not keeping up-to-date with the requirements, status will be changed to “Certified – not meeting MOC requirements.” If after 6 years one is not up-to-date with requirements, then that doctor would no longer be board certified (despite having passed the exam 6 years prior!) A diplomate may change his/her status back to “Certified – Meeting MOC requirements” upon successful completion of a block of MOC requirements and payment of all required fees.

This entire process is completely unfair. I have no problem meeting MOC requirements if I have to, though I also think that that is a farce because it does not confer upon any doctor any special status as far as clinical acumen or excellence as a physician. It solely proves that a doctor can find suitable credits to pass to satisfy the requirement. Many of us lead very busy lives, not only in practice but outside of work, and really don’t need more to do. I own and operate a completely solo practice and do all my own administrative work. I don’t need more to do. I earn the requisite number of credits each year to satisfy ABPN and state board requirements. How can the board not only justify more onerous requirements but then make us pay for the “privilege” of such upkeep? This smells like profit mongering on the part of ABPN, just like the ridiculous burden and cost of needing to recertify every 10 years for those of us who graduated after 1993. EVERYONE should need to recertify, or nobody at all. If I choose to recertify in 10 years, I would still rather pay once at that time rather than give the ABPN any of my money annually. The CEO of the ABPN is already paid over $800,000/year, so it is obvious where the money is going. I am not in business to help keep the ABPN afloat and am truly hopeful that soon enough there will be other certifying boards that become accredited. I may have one more certification in my career, but if I have another option I will gladly move away from the ABPN at that time. I would love to continue this discussion with whoever is making these decisions.

A Change is in Order: Mail Order Disorder & Health Insurance

Normally, ordering a 3 month supply of prescription medication from Future Scripts (https://www.futurescripts.com/FutureScripts/), a subsidiary of Independence Blue Cross (https://www.ibx.com/index.jsp), was nothing more than logging in, clicking on what needed to be ordered, and then checking out. But just a few weeks ago, I noted that when I tried to do so by clicking the link https://portal.myfuturescripts.com/MyFutureScripts/mail_order_saml?redirectToMailOrder=true., I was informed that there was an error in logging into the site. Double checking the password was correct changed nothing. I called my family doctor’s office to have them send the prescriptions instead, and got a notification from Future Scripts that my order was being processed as well as a phone call to my home number asking me to verify my address (something I have never had to do before). I was given a deadline of August 31 at midnight to respond or the order would be canceled. I called and learned that the order had already shipped and the person who took my called was just as puzzled as I was that: a) I had gotten that call when everything about my order and shipping address was clear, and b) despite the need to confirm my address, the order shipped anyway before I called. She also informed me that it looked like Future Scripts was now going to be placing that same call with each order because my shipping address, as it has been, has been my office to assure that someone is present to get the order rather than have it sit in a hot (or cold) mailbox or be sent back if there is a signature required. I was further unpleasantly surprised to learn that Future Scripts was actually no longer administering my 3 month prescriptions because Independence Blue Cross had taken over that function. Moving forward, I would have to sign into https://www.ibx.com/index.jsp instead. I did that just to check and after a few false starts found that my Future Scripts password worked for that as well. I was also informed that Independence Blue Cross had NOT told its members of this change, and had instructed customer service to tell members who call Future Scripts to log into their website instead without providing any explanation about how such a change had been rendered without informing members about it. This in essence forces those who use the online ordering service to have to make a time consuming call to a toll free number, wading first through the irritating mechanical voice options asking numerous innocuous sounding questions that on a more sinister level seem designed to irritate and frustrate those who call. Sure, automated voice protocols save time and money for the company, but as with all things insurance related, more and more of the cost is shifted to us, the consumer/member/“covered lives” that these companies so depend upon for their existence. Just out of curiosity, I logged in again to Future Scripts mail order services today, but when I clicked the link noted earlier, this time I got a new message:

2020 Thank you for your interest in online pharmacy services. Our records indicate that you are not eligible for Pharmacy Benefits. If you feel you have received this message in error, please call the number on your ID card. Please refer to error code 2020.

I know I still have 3 month pharmacy benefits. The policy we have has not changed at all except to have gotten more expensive for the new year while offering less. I cannot imagine calling again to find out what I already know. What is troubling is that if I am getting that message, how many other people will be too and how many people will be sent into a panic as a result because of the information presented in such a message? How many phone calls to Future Scripts and/or Independence Blue Cross will that generate? One would think that such a change in pharmacy benefits management would have been made very clear to all covered members at the outset, but what incentive do they or any insurance company have to be proactive? Instances like these do nothing but promote the continued disgust and malice the public often feels toward insurance companies. During a time when premiums continue to increase for diminishing and more restrictive services and benefits, there is this to consider:

Thirty-three people who served as the CEO of a Blues plan for some or all of 2014 collectively earned more than $26 million in salary and about $102 million in total compensation, which includes bonuses, 401(k) retirement contributions and other incentives, according to data supplied by state regulators in response to The AIS Report’s Freedom of Information Act requests and other inquiries. https://aishealth.com/archive/nblu1015-01

The numbers were roughly the same in 2015 according to the AIS report for that year. http://www.streetinsider.com/Press+Releases/Despite+Flat+Salaries,+Blues+Plan+CEOs+Collectively+Earned+$102+Million+in+2014,+AIS+Newsletter+Reports/10931041.html

In 2014, Daniel J. Hilferty, the CEO of Independence Blue Cross, saw a 6.2% increase in his total compensation to nearly $3.8 million per year. I don’t begrudge anyone the opportunity to make a good, or even amazing living. In comparing Hilferty’s salary to that of a Hollywood star or a star athlete, it pales in comparison and would be considered modest. However, when one looks at the aggregate of all executive and board compensation packages across the insurance industry, it is quickly evident where the majority of the disposable income is going after accounting for usual business expenses – not to patient care. In 2015, his counterpart at UnitedHealth Group, Stephen Hemsley, received total compensation in 2015 of $14.9 million, David Cordani of Cigna – $14.5 million, Joseph Swedish of Anthem Blue Cross – $13.5 million, and Bruce Broussard of Humana – $10.2 million. George Paz of Express Scripts, a pharmacy benefits management company like Future Scripts, earned $12.9 million in 2015. http://medcitynews.com/2015/06/what-were-the-top-healthcare-ceo-salaries-last-year/

So where does this leave us as consumers, as physicians? As a doctor, I am constantly faced with challenges to my decisions, largely in the context of prescriptions and what insurers think is appropriate or “medically necessary.” I have written elsewhere about both prior authorizations and why generics not always a good thing, but it goes beyond that. I realize that there are finite dollars to spend and that cost containment is a sensible consideration in any industry or business. As a dramatic example, a person complaining of a headache should not automatically have a brain MRI, which is very expensive and most often overkill for what may resolve on its own with no consequences. As physicians we need to be ever mindful of listening to our patients and thinking about the problem(s) presented as opposed to knee jerk orders for testing and other consultations in the name of being “thorough.” Insurance benefit limits can serve as a reminder for that. However, the health insurance industry is unlike no other industry because the direct currency is human life, and insurers are continually translating, or converting, if you will, that currency into dollars. Decisions made are on an endlessly cycling ethical slippery slope and there seems to be little that can be done at present to stop that process. But that is not to suggest that we are paralyzed and can do nothing. Change is always inevitable, so it would be up to us to try to direct that change in a positive direction.

For change to happen, there would have to be a consistent and sustained effort that speaks the monetary language of insurance companies. Employers, as represented by their human resources departments, need to work on harder negotiations with insurance companies. The larger the employer, the louder the voice. Joining health insurance purchasing cooperatives is one way to enhance bargaining power. A health insurance co-op (consumer operated and oriented plan) is not a new idea, and some of the first such groups began to appear in the US in the 1990’s. Elliott Wicks of the Economic and Social Research Institute wrote about this in 2002 in an issue brief for The Commonwealth Funds Task Force on the Future of Health Insurance. (http://www.commonwealthfund.org/usr_doc/wicks_coops.pdf) In it he noted that at that time there had been a number of successful co-ops, but also numerous failures and he reviewed the various reasons for those failures as well as for the successes. One point he raised that was striking was this:

In the future, co-ops might be able to offer more attractive prices, but that would depend on reaching “critical mass” size. To offer attractive prices, a co-op has to be able to realize administrative savings and/or have bargaining leverage with health plans. Both these conditions require that co-ops control significant market shares

But he also realized that it is difficult to reach that “critical mass size,” and warned against co-ops becoming a vehicle for pooling high, medium and low risk employers because of possible “adverse selection.”

In 1995 there were at least nine states that had formed some type of health insurance purchasing cooperative (HPC) or alliance. By early 2009, there were at least 28 states with such cooperatives mandated by state law or regulation. The federal government has also been involved in the creation of co-ops. Indeed, one mandate by the government was that a co-op “must operate with a strong consumer focus, including timeliness, responsiveness, and accountability to members in accordance with regulations to be promulgated by the Secretary of HHS.” For a more in depth review of the current state of co-ops, I refer the reader to http://www.ncsl.org/research/health/purchasing-coops-and-alliances-for-health.aspx.

While I think co-ops are a valid concept, it seems that a number have failed, though many continue to exist and do well. The bigger issue we face is the amount of power wielded by insurers. Who is regulating them? Among insurers, for 2016 Blue Cross/Blue Shield contributed the most money to political campaigns and parties at $6,555,994, while the total for the insurance industry for 2016 thus far has been $75,672,091. https://www.opensecrets.org/lobby/indusclient.php?id=F09

During the 2012 election cycle, the insurance industry contributed a record $58.7 million to federal parties, candidates and outside spending groups https://www.opensecrets.org/industries/indus.php?ind=F09

While a discussion of PAC’s, lobbying and campaign contributions is beyond the scope of this essay, the point here is clear. The language of currency is universally understood and is perhaps the most effective form of communication, which is how insurance companies have been permitted to use loopholes such as ERISA (see a previous blog entry) and avoid litigation as well as more definite federal and state control of how they operate. The net effect has been a good enough immunization against social forces or consumer discontent that might otherwise ultimately force a change in restrictive processes such as prior authorizations, dosage limitations and other forms of treatment denial. The argument on their part has always been that they are not denying treatment, but rather refusing to authorize it, which means it will not be reimbursed. Again, currency is the loudest and most effective voice.

Perhaps, though, there is hope kindling at present. As I have reported elsewhere, litigation against insurance companies is beginning to become more commonplace. For instance, there is the lawsuit in New York against UnitedHealth Group for violation of mental health parity laws. And more recently, United States Attorney General Loretta E. Lynch recently announced that the federal government, in an effort to ensure competition and fair pricing, is suing to block the proposed Anthem Blue Cross-Cigna and Aetna-Humana mergers. Listen here as Bill Baer, the Antitrust Chief of the Justice Department, explains what is happening: http://www.nytimes.com/2016/07/22/business/dealbook/us-sues-to-block-anthem-cigna-and-aetna-humana-mergers.html?_r=0

UnitedHealth Group had announced in April it was pulling out of the health insurance marketplace established by the Affordable Care Act (Obamacare). Humana and Aetna more recently announced the same intentions. All are claiming financial losses because individuals who might not otherwise have been insured are getting insured and tend to be sicker, according to reports, which means more money HAS to be spent on patient care, driving down corporate profits. Is a CEO seeing a total compensation of over $10 million really going to feel that? Perhaps – it’s not for me to say. But crying poor all of a sudden because a company has to do what it was originally intended to do – insure people for health care coverage – is ethically sickening.

If it weren’t so tragic it would be funny: the ongoing prior authorization nightmare

If it weren’t so tragic it would be funny: the ongoing prior authorization nightmare

My latest entry will discuss yet another set of incidents of egregious behavior on the part of an insurer. This time it is involves a series of cases handled by Future Scripts prior authorizations department as well as their mail order pharmacy. Future Scripts which has a pharmacy benefits management arrangement with Independence Blue Cross.
https://www.ibx.com/individuals/member_resources/pharmacy/
In one particular incident, Future Scripts  http://Future Scripts received the patient’s mail order for generic Concerta, an ADHD medication, around October 1. Two weeks later the patient had yet to receive the mail order three month supply, though Future Scripts left a message on her home phone “apologizing” for the delay and then giving their toll free number to call with questions. To make matters worse, the mail order form explicitly stated that the shipment was to go to her father’s office because he would be there to receive it whereas if nobody were home when it came to the house, it would be sent back because it requires a signature given that it is a controlled substance. Of course, for the second order in a row, Future Scripts sent it to her home, either completely ignoring the shipping address or failing to read the form and using the default member address. Luckily for her, she still got it, albeit 2 weeks late, because the postal carrier failed to follow through with instructions to get a signature, and that was after Future Scripts apparently talked with her local post office to assure that would be the case. A call to a Future Scripts supervisor produced admission of the error in shipping as well as a promise to “get to the bottom of why that happened.” To her dismay, she opened the bottle and the pills were not the same as the last prescription. Indeed, they were not the specified authorized generic by Actavis, but rather one that had been downgraded by the FDA to a BX rating, which means it is no longer considered bioequivalent. She had gotten this once before prior to knowledge that the change in rating had taken place and its clinical effect did not last through her day and she had more side effects as well (anxiety, headache) compared to either the actual brand or the Actavis generic. For more about this, check http://www.fda.gov/Drugs/DrugSafety/ucm422568.htm

New prescriptions were then provided to her, one for the 30 day supply she needed to get at the pharmacy and another 90 day prescription. Future Scripts, after being demanded to to so, refunded the copay she paid for the wrong prescription. She went to fill the 30 day prescription and…..a NEW prior authorization was required for an override, given she had just received the previous prescription last week. Imagine that?! Future Scripts informed me that they could (or would) not authorize from their end it but instead would require that a new prior authorization request be sent for their review, which sometimes takes two separate attempts, as I have often found that my first request is completely ignored. Many times I send the request again, only to get back a puzzling response that there is already an authorization in place or the ubiquitous but nebulous request that “more information is needed” (which is usually just a repeat of everything I have already provided and nothing more than an answer to their request for more information). She still does not have that authorization as of this writing and therefore still is without the proper medication.

In another series of Future Scripts mishaps with a patient’s medication that evoked the old Keystone Cops (https://en.wikipedia.org/wiki/Keystone_Cops)
I had sent an authorization for an antidepressant, Fetzima, for a patient who was in need of this. It took several attempts, and multiple replies to the “more information needed” type of requests, to get it approved. Things were fine from that end but the medication did not work for her, so it was changed to another drug in its class, Pristiq. Each time I sent the prior authorization request that Future Scripts demanded, (the medication was refused at the pharmacy because Future Scripts was refusing coverage till the prior authorization was completed), I received the following response repeatedly:

The above drug does not require review for the member listed above because null Member may have the prescription filled with applicable cost-sharing.

Repeated attempts to get Future Scripts to clarify this were met with the same letter. This occurred toward the middle through the end of September and as of this writing at the end of October we still have no answer. Fortunately I have been able to supply her with samples while we are still trying to get the issue resolved.

Future Scripts has really been on a roll lately. There is yet one other example I would like to highlight for my readers. I recently evaluated a new patient and diagnosed her with bipolar disorder. Often, people with this illness suffer from chronic sleep problems and she was no exception. The generic form of the sleep drug Lunesta was prescribed because it was one that she had not yet tried; others tried had failed. Given the severity of her sleep problems dating back to childhood, I decided that the 3 mg dose – the maximum dose – would be the most clinically appropriate choice. In their infinite wisdom, Future Scripts, despite never evaluating my patient, determined that that was not the case and after sending again two requests they informed me that the 1 mg and 2 mg options would need to be tried and shown to fail before they would consider the 3 mg strength. I played the game, resubmitted a request, and got yet another denial – for 3 mg, AGAIN. I submitted the lower dose request again and got back this reply:

The above drug does not require review for the member listed above because generic Eszopiclone 1 mg and 2 mg do not require prior authorization; the patient must receive a 30 day trial and have therapeutic failure to one of the two aforementioned strengths of Eszopiclone to receive approval for Lunesta/Eszopiclone 3 mg. Member may have prescription filled with the applicable cost-sharing.

What was not clear then was why the lower dose was still being denied at the pharmacy.

Clearly, something is terribly wrong with the way insurance companies can interfere in patient care. Perhaps there is some reason to take heart, though, based on a recent decision rendered in the US Court of Appeals, which ruled in favor of NYSPA (New York State Psychiatric Association) and the APA (American Psychiatric Association against UHC (United Healthcare), permitting a lawsuit to go forward against UHC for violating the federal parity law for mental health and dismissed all objections raised by UHC, which opens the doors for future claims against insurers. Maybe this is the first step to erode the ERISA shield insurers hide behind when making administrative decisions that interfere with or compromise clinical care. For more about that read here: http://www.nyspsych.org/index.php?option=com_content&view=article&id=304%3Aunited-healthcare-decision-8-20-15a&catid=20%3Asite-content

For more about the impact of ERISA on health care, read here:
http://www.huffingtonpost.com/wendell-potter/congress-needs-to-close-l_b_2271531.html
http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=1099&context=yjhple

If you are a patient reading this, collaborate with your doctor to fight against denials of treatment, whether it is a prescription or some other aspect of your care. Remember, if you have a grievance you can also submit a complaint to your state’s insurance commission. http://www.naic.org/state_web_map.htm
Physicians and other health care providers, I know how time consuming this process typically is and I know the frustration it causes, but we are often both the front line and the last line of defense for our patients, many of whom don’t have the resources or energy to stand up to their insurance companies. It is incumbent upon us to be advocates, and if we can’t personally to designate someone on our staff to do so to meet patient needs.

The Future is Scripted

Future Scripts (https://www.futurescripts.com/FutureScripts/) is another pharmacy benefits management company that services Personal Choice and Keystone Health Plan, Independence Blue Cross products. In general, pharmacy benefits management companies serve one purpose – to manage your prescriptions. They typically consist of a mail order branch, which, for Future Scripts, is now Catamaran when it also used to be called Future Scripts, and the “management” branch, which mostly refers to the prior authorization department. Or, put differently, we can call that the treatment denial department. Prior authorizations are becoming increasingly stringent and what is allowed far more restricted. It seems that these companies utilize a number of different strategies. One is to inform patients that “we contacted your doctor and have not heard anything back.” This is often the furthest from the truth but is, I believe, part of the overall script of denial and delay. The longer something is not paid for, the longer the money sits in the coffers of the insurance company. Their latest wrinkle in delaying care was a bit more insidious than the usual denial.

Last week I prescribed a newer antidepressant for a patient. Previously she had been receiving samples but I had run out. She just got insurance and the luck of the draw gave us Future Scripts as the manager. I submitted the prior authorization request without prompting, knowing it would be required. I used their general prior authorization form. I received a call back asking if I was also requesting a tiering exception (which would lower my patient’s copay). There was no option for that on the existing form so I called the number (I dread calling because it is always a waste of my time on the phone). It rang – I counted – 40 times, no answer. Thinking perhaps I had used the wrong number I called again, same result. The third call I placed a pushed an option to speak to an agent and was routed to Catamaran, the mail order pharmacy, and they of course knew nothing about this case nor could they even locate my patient in “the system” using her name, date of birth and insurance ID number! Frustrated beyond belief, I created my own tiering exception form from one of their existing forms and faxed that in before leaving the office. The next day, the same woman who had left me the message about the tiering exception called again. This time when I called back she answered and I vented my frustration. She only added to it by telling me a different technician must have received the second form. She admitted they have NO VOICE MAIL for their extensions, which is why it rang 40 times twice. She also told me that the form I had initially submitted that she saw was actually the correct form for tiering exceptions too but it had no place to ask for that! Frustration comingled with bewilderment at this array of alarming information. After venting some more I informed her that if the medication was not approved WITH a tiering exception by the end of the business day I would file a grievance with the state insurance commission. Magically, both the medication itself and the tiering exception were approved, though of course not before wasting two separate fax transmissions to me to inform me of this. MY patient’s care was delayed nearly a week as a result of this.

And just this week, another company added their special brand of planned incompetence. Aetna (https://www.aetna.com/individuals-families/members-pharmacy-prescription-benefits.html) requested a prior authorization for a patient’s generic Concerta (methylphenidate ER, an ADHD medication). I submitted a request on an Aetna form, but received a phone call informing me an attempt to fax me had failed. I checked the fax log first and it hadn’t failed. My sense of foreboding began to rise. I filled out the newly faxed authorization form and one of the questions I had to answer was the following:

Does the patient have documentation fo symptoms significantly impacting, impairing, or compromising the patient’s ability to function normally (ie., attend/maintain academic enrollment or employment)?

The answer I gave was yes. It was clearly noted, as the box for yes was filled in while the box for no was left blank. I received a faxed back reply with the following reason given for a treatment denial:

The information did not show that you have symptoms significantly impacting, impairing or compromising your ability to function normally as listed below.

There was no list of symptoms below that. I faxed back with a letter explaining that I had already answered yes to that question and demanding a reason for the denial. Again, I was forced to call to speak with a pharmacist, as the technicians who call are not permitted to render decisions but simply gather information from me while reading from some scripted algorithm before handing me off to the pharmacist, who asks all the same questions. Again, a threat of the state insurance commission along with a threat of legal action this time produced a swift reversal of the decision, but no explanation for the denial after the one question on which the denial had been based had actually been answered affirmatively.

If you are a patient reading this, you may have had similar experiences. Hopefully your doctor will go to bat for you or has office staff to do that. If not, you do have recourse by filing a grievance with your state’s insurance commission and by trying to find a law firm that specializes in managed care, or mangled care, as I like to call it.

National Association of Insurance Commissioners: http://www.naic.org/state_web_map.htm

No Silver Lining – Medicare PDP’s

No Silver Lining – the Cost of Medicare Part D Prescription Drug Plans

When Medicare Part D (Medicare prescription drug benefit) was enacted as part of the Medicare Modernization Act of 2003 and went into effect on January 1, 2006, it was haled as blessing to our seniors and anyone else covered under Medicare. The plan was for the federal-government to subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries. I have written elsewhere about this program’s actual effects on its beneficiaries (http://www.physicianspractice.com/articles/underdog-doc-takes-payers-patient), but it is important to write again now as the landscape is changing. Of course, the Medicare Part D program was an incredible business initiative for health insurance companies to jump in and begin wielding there ever sharp carving knives. In Pennsylvania, where I practice, I counted 15 companies, including one partnered with Walmart. Nothing like competition for a slice of the dollar to create an environment focused solely on that very dollar. One of the ways they have consistently been able to keep their daily balance ledgers in a comfortable place to keep their stockholders happy is by becoming every more stringent with prior authorization requirements. On average I work about 10 extra hours a week, all unreimbursed, to make sure patients get their needs met. I realize this poses an extra burden on doctor’s offices, but continuity and quality of care are at risk.

Recently, I was asked to complete the omnipresent prior authorization request for an elderly man’s sleep medication. His Medicare PDP (prescription drug plan) insisted that the sleep medication he had been taking would only be permitted for 90 nights a year. 90 nights a year! So for the other 275 nights of the year his insomnia was supposed to disappear, magically, so Silver Script, the company involved, could save money. He had been taking it for years before ever seeing me and attempts to take him off of it lead to sleepless nights. When he doesn’t sleep for long enough he becomes severely anxious and that can set off his cardiac arrythmia. Weighing the risks and benefits, I decided to make sure the medication was approved. I faxed the requisite form and with the strong wording I usually use, I expected a response from Silver Script within a 24 hour period. Instead, I got another form and a phone call as well asking the same exact questions I had already answered. On the form it asked if I had tried other “non-high risk medications” (I had already provided that information in my fax). My frustration turned to a complete sense of incredulity upon reading their list of non-high risk medications: temazepam and doxepin. Temazepam is a benzodiazepine medication, in the same family of medications as Xanax, Klonopin and Valium and far more “high risk,” particularly in older individuals, then the medication I had requested. Doxepin is an old tricyclic antidepressant that is rarely used for depression but is often used in very low doses for sleep. Tricyclics can cause cardiac arrhythmias and therefore are not necessarily non-high risk medications either. To add to my growing state of alarm is the fact that the form came AFTER there had already been a phone conversation, during which I demanded to know why my original form had been completely ignored. The “pharmacy tech” on the other end kept apologizing and telling me she knew how frustrating this must be, though I wondered if she was sitting with an algorithm sheet of what to say to irate doctors in the same manner they have algorithms to ask questions about the prior authorization request in the first place.

Prior authorization requests are becoming increasingly common not only for more costly brand medications, but for quantities of medications allowed per month. That’s right – quantities are not also being more tightly regulated. It doesn’t matter if you’ve been taking a certain amount for a long time. Your doctor will become ever more likely asked to complete a prior authorization request to make sure your treatment can continue uninterrupted. What can you do to advocate for yourself?

  1. Know your benefits well, and if you are having trouble deciphering all the insurance company speak, find someone who can help you understand it.
  2. Don’t take no for an answer. That means don’t immediately accept a change in a medication that may have stabilized you in favor of some less costly generic medication (see my earlier post about generic medications and the possibility that they may be inferior http://www.danielblockpsychiatry.com/). In addition to the prior authorization your doctor or his/her designated administrator can demand a lower copay tier under your Medicare PDP. I have done it several times for patients.
  3. If your receive a negative outcome, there are appeals and grievance proceedings, but let’s face it. The 5-10 page document the insurer sends outlining the appeal process is cumbersome and full of dense language. Your doctor can cut through some of this bureaucratic mess by demanding to speak with a supervisor, but both you and your doctor can place a complaint with your state’s insurance commission. The link here is to an interactive map for the insurance departments of all 50 states: http://www.naic.org/state_web_map.htm
  4. Write to your State Representative and State Senator with your grievances. Remember, they depend on your vote to get into office. Let’s remind them they need to listen to their constituency if they hope to get re-elected.
  5. If you have access to the media, see if you can be interviewed by a local newspaper or radio/television program. Also, if you or someone you know is tech savvy, start a website or blog for complaints about insurers. This can be easily done using Facebook (www.facebook.com)

I am hoping that this post will help people on Medicare Part D plans or their families to maintain a sense of participation in their own care while understanding better the current climate in health care.

TIERS TO TEARS

I have written a number of times about the various practices that insurance companies employ that keep people from getting their needs fully met. Specifically, I have focused on the prior authorization process. So what can happen when it initially seems to go well? I can submit a prior authorization request and have the request approved and all seems good, right? I received a distressed phone call from a patient of mine for whom I had gotten approval for the brand name version of Wellbutrin XL (bupropion extended release), a highly effective antidepressant that does not cause sedation, weight gain or sexual side effects. Unfortunately, her insurance company failed to mention that it would be approved but at the highest level of pay. This is known as the copay tier system, one in which there are preferred generics, non-preferred generics, preferred brand names and non-preferred brand names. I have yet to be able to get an explanation from anyone at any insurance company as to how these tiers are determined, which leaves me to speculate, though I believe my guesswork is most likely quite accurate. Medications are chosen for the various tiers based on the cost to the insurer. So the patient’s Wellbutrin XL 300 mg tablets were “covered,” but at roughly $600/month! The generic would have been a “normal” copay, which would be anywhere between $10-$30/month, which is much more palatable. This patient requested a prescription for the generic with the knowledge that it might not be as effective. The trouble with this particular generic, which was made by Teva, began when an independent consumer lab tested it and found that it was releasing about a third of its contents in the first 2 hours, as opposed to the normal 8% of the brand name. About 5 years later the FDA finally decided to pay attention and mandated that generic makers of the 300 mg dose, the dose in question in this case, pull their products and re-evaluate them. Teva’s product was not permitted back on the market and was therefore withdrawn. The same product made by Impax was also withdrawn. Furthermore, the FDA did not test the generics from four other makers – Anchen, Actavis, Watson, and Mylan. That was well after there were also lawsuits (to learn more, http://www.medhelp.org/posts/Depression/Problems-with-Budeprion-XL-generic-Wellbutrin/show/1012337). It seems that when the FDA originally approved the 300 mg generic, it based that decision on the efficacy of the 150 mg dose, never really requiring testing of the 300 mg dose (to learn more, http://www.drugstorenews.com/article/fda-issues-new-guidelines-budeprion-xl-300-mg-strength). A drug rated by the FDA as AA is the exact equivalent, meaning there are no known or suspected bioequivalence problems, or if there were, they were resolved in satisfactory fashion. An AB rating includes products that meet necessary bioequivalence requirements. Please see my previous blog about the 80-125% rule to better understand this category and therefore waht AB truly means. My patient is presently relegated to an AB rated product that has a history of bioequivalence problems, with two previous generics having been removed from the market in the 300 mg form. There are three brand name versions of bupropion XL: Wellbutrin XL (http://www.drugs.com/cdi/wellbutrin-xl-extended-release-tablets.html), Aplenzin (which is actually bupropion hydrobromide, not hydrochloride, though that difference does not have clinical ramfications) (http://www.drugs.com/aplenzin.html), and Forfivo XL (http://www.drugs.com/price-guide/forfivo-xl), a niche product focusing solely on the top dose, 450 mg. To learn more about the FDA’s AA vs AB rating system, please see http://www.fda.gov/Drugs/DevelopmentApprovalProcess/ucm079068.htm#Therapeutic%

20Equivalence%20Evaluations%20Codes. For now, I can only hope I can manage to procure more brand name samples of either Wellbutrin XL or Aplenzin to supply to my patient. If you are having issues with this particular drug and in a generic version that seems not to be working, talk with your doctor about the brand name. But first, learn your insurance company’s copay tier system, because the prior authorization may mean nothing once you see the sticker price of a month supply.

GENERICS do not equal BRAND: The 80-125 Rule

GENERICS do not equal BRAND: The 80-125 Rule

Your insurance health plan’s prescription benefits clearly state that when and where a generic is available, you have to try a generic or incur a higher cost, either meaning a higher copayment of no coverage at all (that means you pay out of pocket for the full retail price of the drug). In so many cases, generics are allowed. And why shouldn’t they be? After all, they’re FDA-approved, right? And it’s common knowledge that generics are the same as, as good as, the brand name. And doesn’t everybody knows that brand names cost a lot of money because the evil Big Pharma is out to make a profit? So why not generics?

In many instances, generics do actually perform just as well as the brand name without any increase in side effects or drop off in therapeutic effect. Take Prozac, for instance. It became widely available in the US somewhere around 1990 (it was FDA-approved in 1987). Its patent expired in 2001, and generics were soon available. In my practice, I have had many patients taking the generic without any problems. I had no problem prescribing it because I have always been cost-sensitive and don’t want my patients having to pay more than they have to to be able to afford quality care. But I also remembered being taught in psychiatric residency training that the FDA actually permits a generic drug to be determined “bioequivalent” if its contents are 80-125% of the targeted dose. That means that a 100 mg dose of Brand X could essentially be anywhere from 80-125 mg of generic X and still be considered “bioequivalent.” To learn more: http://www.consumer-health.com/services/5CommonQuestionsAboutGenericDrugs.php

Several years ago, a patient with bipolar disorder called me complaining of all the symptoms of depression except this patient was not depressed. Symptoms included weight gain, sluggishness, fatigue, increased sleep, decreased energy and concentration, poor motivation and loss of drive to do the things normally of interest to this person. I immediately ordered a lithium level and it returned in the toxic range. It was nothing that stopping the drug for 24 hours couldn’t correct, but it concerned me because her dose had not changed and had the level been a few tenths of a point higher, we would have been looking at a hospitalization. I asked my patient about any medication changes, new medications or any other new medical conditions. The answer to each question was “No.” I asked if the color or shape of the pills had changed and the answer was yes. It turned out that the brand name lithium this patient had been taking had been switched over to a generic. That was the only change. The 80-125 rule was in effect.

Not long after that, patients of mine began complaining whenever their Wellbutrin XL 300 mg was changed to the cheaper generic, Budeprion XL 300 mg, manufactured by Impax Laboratories, Inc and marketed by Teva Pharmaceuticals. In 2008, an independent consumer lab was able to demonstrate through testing that the generic version was dumping roughly 34% of its contents into the blood stream within the first two hours of ingestion, whereas the brand name drug released 8% in the same time frame. Patients were complaining of increased side effects and a recurrence of depressive symptoms. It wasn’t until March 2013 that the FDA formally withdrew the drug from the US market as an approved generic, though it had asked Teva to stop distributing it in September 2012. Contrary to the FDA’s study in 2007 that concluded the two were bioequivalent, the 2012 review concluded that “Budeprion XL 300 mg fails to demonstrate therapeutic equivalence to Wellbutrin XL 300 mg.” Watson Pharmaceuticals, which purchased Actavis (a company that was months behind in submitting tests bioequivalency tests to the FDA for its version of generic bupropion XL), agreed to voluntarily pull that product from the market in October 2013. To learn more: http://www.raps.org/focus-online/news/news-article-view/article/4184/second-generic-version-of-popular-antidepressant-to-be-pulled-from-market-for-b.aspx.
Further information can be found at http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformation
forpatientsandproviders/ucm322161.htm

And in July 2014, the FDA announced that over 40,000 bottles of generic venlafaxine ER (generic for the antidepressant Effexor XR) had been voluntarily recalled by Sun Pharmaceutical Industries, an Indian drug company, for failure to meet “drug dissolution specification.” Drug dissolution is a way to understand how a drug behaves in the body. The FDA classified this as a Class II recall, which means that using the product could cause temporary or reversible negative consequences. To learn more:
http://www.accessdata.fda.gov/scripts/enforcement/enforce_rpt-Product-Tabs.cfm
action=select&recall_number=D-1415-2014&w=07092014&lang=eng

It is vitally important for patients to be aware that generics are NOT necessarily equal to the brand name medication. A return of symptoms is not necessarily a call for more medication or a change in medication. In my practice, I have been telling patients to inform me of any change in color, shape, pill type or other changes whenever they receive each new prescription. Typically, health plans will purchase the cheapest generic available, so this is especially important with your mail order prescriptions. Doctors who may be reading this should adopt a similar practice of educating patients about eh 80-125 rule if not already doing so and encourage patients to adopt a similar reporting practice each time there is a prescription renewal. Additionally, with a little effort (ok, sometimes a lot), doctors can get the brand name approved AND a cost exception to the copay tier with the submission of the proper documentation to the insurance company. It may mean threatening filing a grievance with the state’s insurance commissioner and/or legal action to get the job done, but as physicians we need to advocate strongly. Also, in cases where there is no insurance, patients may be eligible for patient assistance from the drug manufacturer, which means they can receive free supplies of the brand name. I have a number of patients who are benefiting from these charitable services.

 

 

Take Two Aspirin and Call Me…Oh Wait, is Aspirin on the Approved Formulary?

So, here is another great example of why I get so fired up about insurance plans and the prior authorization process. For privacy reasons in this case, I will not reveal the name of the health plan. Below (redacted to preserve identity) is what I sent explaining my choice of Rozerem, a non-addictive sleep drug. Despite what I wrote, I was told that temazepam or zolpidem had to be tried first.

Insomnia has been an issue with patient A. Patient A cannot take benzodiazepines (temazepam, estazolam) for sleep because of a history of addiction. If there is random drug screen at work that class of medications will produce a positive urine. Zolpidem (IR, CR), zaleplon and eszopiclone may also pose abuse risks. Also, zaleplon is NOT indicated for chronic, persistent insomnia and is only used for initial insomnia or middle insomnia anyway. Patient A tried trazodone but was far too sedated the next day, even on a very low dose. If his Patient A’s insomnia is not treated, Patient A cannot function the next day at work and also notes worsening depression. Rozerem is one of only two sleep drugs that are FDA appoved for long term management of insomnia (eszopiclone (Lunesta) being the other) and it has no dependency potential.

How much clearer could I have been? The medical director with whom I spoke assured me that “the forms get scanned into the computer and sometimes we don’t get all the information sent over.” It should be noted that there was only one form with one page of actual patient and clinical information. I was told that the medical director who reviewed, therefore, must not have “gotten that page,” but when I asked him to look at what they had received, he began reading from the same page that I had sent. When I directed him to the box for written explanations, he then saw the above paragraph. He had no explanation why it had either been ignored, perhaps not read at all, or deemed not important enough not to deny the Rozerem. Multiple times, he assured me that he will “have to look into this.” How empty that sounded. This was not the first time with this health plan that I had the same issue with the same. Of course, after speaking with me (which took three separate calls), the Rozerem was approved.

If you are a physician reading this, please know that though this is very time consuming and causes a lot of aggravation, our patients are not at fault nor responsible for their insurance plans. And we shouldn’t have to go through such as arduous process each time we want to prescribe a medication. If you are a patient or someone who has been on the other end of one of these decisions, know that with some diligence and persistence on the part of your doctor of the doctor’s staff, you can get the medication he or she prescribed originally. It should never be that the insurance company should be making decisions about your care.