Denial of Care

September 12, 2013

Recently, I questioned the old adage, “time heals all.”  While time may heal many hurts, time can also be your enemy.  Give an infection time to spread and it may kill you.  Yesterday, I treated a middle aged patient for a bacterial bronchitis.  After assessing his history, physical exam, lab findings and chest x-ray, I prescribed an appropriate antibiotic and cough medicine.

My patient went to the pharmacy and was refused his antibiotic.  On my desk this morning was a request for prior authorization for his GENERIC prescription.  Yes, I had prescribed a generic medication and his pharmacy benefits manager still refused to cover it.  Yes, my patient’s therapy has been delayed by a company whose quarterly profits depend on denying medical care.

The message I received read, “Plan does not cover this medication.  Please call plan at (800) Screw-Everyone to initiate prior authorization or call/fax pharmacy to change medication.”  So, I called the pharmacy and discussed options.  My patient is allergic to one of the alternatives.  A second alternatives risks include causing tendon injury and is too broad spectrum in its coverage (increasing the risk of bacterial resistance in the general population.)  A third option is to be taken 4 times a day on an empty stomach.  Can you imagine taking an antibiotic 4 times a day for 10 days 1 hour before meals or 4 hours after eating?

I called the 1-800 Screw-Everyone and spent 10 minutes on the phone with a clerk.  I was angry to say the least.  I also got nowhere.  I requested to speak to a supervisor and was placed on hold.  I responded to, “I’ll put a supervisor on in just a moment,” with a request to have a supervisor call me.  It’s been two hours and no call.

I’ve informed my patient of his choices.  He will pay cash for his medication.  Hopefully, after a 12 hour delay in his therapy, he will recover.  Whether he recovers fully or not, the pharmacy benefits manager (insurer) wins.  By denying care, they saved themselves the cost of his medication.  If his condition worsens requiring hospitalization, his medical insurance company will pick up that cost.  We live in a sick world where the doctor’s ability to practice medicine is second guessed and altered by corporate entities whose reason to exist is to generate profits.  We live in a world where pharmacists are not free to fill legally written prescriptions but find themselves at the mercy of those same greedy corporations.  Unfortunately, pharmacists rarely ever advise their clients to pay cash for what they need now and deal with their insurers later; instead care is delayed and patients suffer while approval is considered by the all powerful insurance companies.

As long as the public accepts the abuse dished out by insurers, abuse is what they will get.  If your insurer denies your physician’s prescription and the medication is critical to your health, buy it with cash and then fight with your insurer.  Delaying treatment can be physically, emotionally and financially devastating.

posted at www.livewellthy.org