Insurers will plunder until patients demand value for their money


Welcome to my day from hell.  It is 2 p.m. and I’ve just logged my fifth prior authorization denial of the day.  In simpler terms, five patients will either change their medications or pay for them out of pocket.  Personally, I’m sick of this crap.

When it comes to prescribing medication, I am very judicious in my prescribing habits.  According to one of the largest insurers, my percent of generic prescriptions is higher than the national average.  I carefully weigh the benefits of one medication over another and prescribe what is right for the individual I am treating.  I discuss the medication choice with my patient.  My patient then goes to the pharmacy where the information is recorded and transmitted to the patient’s insurer.  Since the first of the year, insurers have been aggressively denying care.  You would think they were losing money.

Instead, insurers’ rates are rising, their profits are rising, and patients are being told they must fail on cheaper alternatives.  Yes, you must fail before you can succeed (assuming your failure does not kill you).

Patient #1 must stop taking the medication that is controlling his neurogenic pain.  Pain produced by a malfunctioning nerve can be extremely severe.  Patient #1 must go on an older version of his current medication.  In its day, gabapentin was a good medication.  Unfortunately, doses capable of relieving significant pain made people groggy.  Patient #1 can save money and be groggy, suffer with pain, or pay out of pocket.  I assume the insurer is betting that Patient #1 can’t afford to be groggy (he is employed and has a life to live) and will pay out of pocket rather than suffer in pain!

Patient #2 has a truly horrible history of heart disease.  His cholesterol profile is just as horrible.  He is on a high dose statin (for the control of HDL and LDL) and still has markedly elevated triglycerides (another dangerous fat in his blood stream).  He has taken over-the-counter fish oil to no avail.  His insurer denied my request for Lovaza, an FDA approved medication for the treatment of his disorder.  In this case, there is no generic nor similar medication.  There are other generic medications that treat high triglycerides, but they all have the potential to adversely interact with his statin.  Patient #2 can either pay out of pocket for his Lovasa or risk a ride in an ambulance or hearse.

I won’t bore you with the particulars of patient #3, 4, and 5.  They all get the pleasure of attempting to fail or spending hard earned cash on both insurance premiums and medications.  Every year this situation gets worse.  Insurers grow stronger, seeking ever increasing profits at everyone’s expense.

As your doctor, I can only do so much.  My staff fills out seemingly endless forms, only to get denials.  As a patient, you have multiple recourses.  Most patients fear insurers and will not challenge them.  They simply pay up. Others go to their HR department and fight.  Those who are self insured should contact their agents or brokers and fight for the right not to fail.  Brokers make their living selling insurance and, when their livelihood is challenged, can accomplish what doctors and patients cannot.

Until the public demands value for their money, insurers will continue their plunder.  Take control of your health.  Do everything you can to maintain your body.  It’s yours for a lifetime.  The healthier you are, the less you will need insurers and medications.

Stewart Segal is a family physician who blogs at

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