Blog | Friday, March 15, 2019

Insurance company denies coverage for drug

A patient came to see me recently with a suspicion that his colitis was recurring. In general terms, colitis describes a condition when the large intestine is inflamed or irritated. Typical symptoms are diarrhea, abdominal cramping, and rectal bleeding. This patient was concerned as his last three bowel movements were diarrhea. He had been on a medicine called mesalamine, a safe and effective treatment for colitis, but he ran out of it 2 weeks ago. While he was taking the medicine, he felt perfectly well. So, his bowel change developed 2 weeks after he ran out of his medicine.

For readers who like to play doctor, choose among the following options:
• Schedule an urgent colonoscopy to verify that nothing has changed since his colonoscopy 6 months ago.
• Observe the patient without any treatment to give him time to heal himself.
• Recommend probiotics to restore his digestive health.
• Refill the mesalamine at his usual dosage.
• Request a second opinion because the case is mind-bogglingly complex.
• Prescribe an antibiotic because most cases of diarrhea are caused by an infection.

I thought that the most reasonable option was to reunite the patient with mesalamine, which had been extremely effective. Moreover, since the symptoms developed after a 2-week medication hiatus, this suggested that his colon was pleading for a medication refill. The patient, who is not a doctor, also thought this was the optimal choice, since he attempted to refill the mesalamine on his own prior to seeing me. However, he had new medical insurance and their response to the routine refill request was DENIED!

How it continued became a gerbilesque experience. We all felt like we were running on a wheel, expending lots of energy and effort, but with no traction. The patient had developed symptoms 2 weeks after he ran out of the medication. I surmise that 100% of gastroenterologists surveyed would have agreed that refilling the medication was the next step. So, even though the best medical option was to refill the medicine that we know has worked, the new insurance company won't cover it and the patient cannot afford to pay retail for the drug. (As a separate point, I challenge anyone including those with PhD's in economics to explain retail drug pricing.) The patient did his best to navigate the insurance company's website and found a colitis medicine that is covered, but it is medically inferior. Should we just cave and prescribe it to save money and a hassle? Is this an issue that we want on our sick patients' agendas? How would you like to face surgery and be told that the newer clamps and scalpels are out of network, but there are some rusty tools in the back that are fully covered?

I tried using our electronic medical record to ascertain if there were effective alternative colitis medications that would be covered, but neither I nor my staff could get a straight answer on this. If we were to call the pharmacist to ask which colitis medicines were covered, which we have tried in the past, we would be told that we would have to officially prescribe each drug individually in order to determine its coverage status. Doesn't that sound fun and efficient?

Does this vignette show medical care at its finest? How much time do physicians and our staffs burn up on tasks like these? Does this anecdote reinforce the notion that insurance companies' mi$$ions are to protect profits and not patients?

Do we want sick patients and physicians to have to fight just to get medicines approved? Shouldn't they be focused on health and healing? Keep in mind that my patient was not seeking exotic or experimental treatment. He only wanted the medicine that he and I knew could keep him well which is approved by the FDA for his condition.

If an avaricious shoe manufacturer decides to hike prices, no customer will be harmed. If the insurance industry, however, aims to maximize their profits, folks can get sick or worse. If this industry doesn't reform itself, then at some point others will do it for them. Wouldn't they be wiser to earn some good will with their customers and the public rather than create an army of enemies?

Who will be there to defend private insurance companies once the Medicare for All Express gains momentum? If insurance companies won't do the right thing for the right reasons, perhaps, self-preservation will motivate them to do better.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.