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Insurance Rules And Overprescribing Expensive Drugs

I have yet another example of how third party insurance rules obstruct efficient patient care. I was asked to see a patient with fibromyalgia who was asking about about the drug Lyrica she heard about on television (one example of how direct to consumer marketing increases health care expenses).  Lyrica is about the only medication approved by the FDA to treat fibromyalgia.  I don’t know if it really works or if it’s just an expensive placebo effect.

Maybe fibromyalgia is all in the head, and that’s why this medication works.  I don’t really care.  I know it’s FDA approved, which means it has more going for it than most pharmaceuticals used for off label purposes.  At least doctors who prescribe Lyrica for fibromyalgia aren’t going to get charged with homicide for prescribing medications for unapproved reasons.

I notice my patient has Medicaid, the ultimate third party insurance nightmare.  Medicaid has strict rules about what can and what cannot be prescribed without preauthorization.  Preauthorization is the third party insurance method of choice to control costs.  It is a series of roadblocks used to prevent physicians from providing the care they believe is in the patient’s best interest. Third party insurance use of preauthorization is  a time consuming, mentally draining and frustrating experience.   Third party insurance rules force physician offices to spend hours on the phone everyday  defending their medical decisions on behalf of patients.  This uncompensated time is one of the major reasons why primary care is dead.

medication-pill-boxAs a hospitalist I rarely have to worry about thousands of third party insurance rules, medication formularies or preauthorization problems.  Every drug I need as a hospitalist is available. Any xray or or cardiovascular scan I need is at my fingertips.    I rarely know what insurance my patient carries. Every insurance has their own formulary.  I try and pick generics to use for discharge.  I try and pick the cheapest drugs.  I am not fooled by claims of superiority between this ACEi or that, this statin drug or that, this PPI or that.  Only a rare patient requires that extra expense of a brand name drug which is often ten, twenty or fifty times greater than their generic counterpart.

Patients occasionally  bounce back for readmission because they couldn’t afford to fill their medications.  I once readmitted a patient with pneumonia because Happy’s partner discharged them with an unaffordable $200 course of antibiotics.  I was thinking a couple $4 drugs from Walmart could have prevented the  bounce back.   I often find myself battling this problem with doctors who write for expensive statins, inhalers or blood pressure medications which I know will never be filled. The homelss guy on the street isn’t going to fill his Ramipril or his Brovana.  The unemployeed construction worker isn’t going to fill his Crestor or Avandia.  At some point in the discharge process, common sense should prevail.

For my Medicaid patient, I wanted to know whether third party  insurance rules required preauthorization for my Lyrica prescription.  So I called the patient’s pharmacy.  And what was I told?  I was told that I couldn’t get this information without having an actual script written and the actual medication filled.  Only then could the Medicaid carrier tell them if my Lyrica required preauthorization.

How ridiculous is that?  I can’t even check to see if my patient’s third party insurance will pay for the medication before the patient tries to pick it up.  What a terribly inefficient system third party insurance has become.   What are my options here?  I wrote the script.  If the pharmacy won’t fill it without preauthorization, which is only known at the point of sale, then the patient either gets their medication or they don’t.  If it requires preauthorization, good luck finding me.  I’m either gone or I’m off service.  Perhaps I’m in Hawaii.

The only solution as I see it is to contact the primary care doctor.  Man am I glad I’m a hospitalist.  Where I’m free to practice without the constraints of third party insurance rules.

*This blog post was originally published at The Happy Hospitalist Blog*


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