Ok, one thing that is both good and bad is having a blog allows you to rant. Not that I haven’t done this already with prior posts, but today is front and center rant of the month! And the topic is, prior authorizations!
What I do not get after years of these constant intrusions by insurance companies who’s agenda is only about money and control is this: why hasn’t a lawyer, who is equally driven by money and control, and perhaps a little press coverage as a bonus, taken on a case where the disruption in care by not allowing a patient access to medication leads to a negative outcome.
Think about this for a moment. You as a doc write a prescription that is completely indicated for an intervention for diagnosis X, and take into consideration cost, dosage, quantity of tablets, and then some dipshit company that runs the pharmaceutical dispensing arm of the health insurance proceeds to say, “patient can’t have it without prior authorization”. (Oh, by the way, in my readings about how to run a blog, they tell you not to use curse words as much possible; not today folks!)
Well, here is where you readers with any legal background might want to sit up and pay a little more attention to the logic I feel applies to the following process. So, you as Doctor Jones (fan of Indiana) get the usual call from patient Wolfman Jack that he/she can’t get the script you wrote, because the insurance company won’t pay for it. Well, wait a second invested readers, it ain’t that simple anymore about just about paying for it. Why do I surmise this? Because they want CLINICAL INFORMATION for someone of alleged professional authority to review and then decide if the script merits applicability.
Well, here is where you legal eagles need to decipher if my reasoning is flawed, or I have opened Pandora’s Box and found a way to nail these bastard insurers to the wall for their failed logic. Ok, they want me to either say over the phone, but, if you are a little smart and want DOCUMENTATION, make them send you a fax to clarify what they want as information to explain why you are writing for Medication D. And these forms always ask for a diagnosis, perhaps noting meds that were tried previously, and nowadays, some forms want to know symptoms to justify the diagnosis.
Well, I hope readers take the time to read about Respondeat Superior, a little known term in forensic terminology that has consequences, especially liability and culpability, and I ask you to read the link below to see if it fits:
http://en.wikipedia.org/wiki/Respondeat_superior
Here’s my take with what it means, and if I am right, it is time for insurers to face the music, preferably one of a couple of themes, either John Carpenter’s Halloween, or Psycho’s stabbing music in the shower.
If insurers want this information to “justify” them paying for the medication, isn’t that a clinical interpretation in acting as a superior to the treating physician, and if that premise has merit, isn’t the delay in accessing care taking on a clinical intervention, in this case DENYING the care and putting the patient at risk for a negative outcome? What if the medication has the potential to prevent the patient from acting out on thoughts or actions, which is what mental health care is about, eh?
I don’t want this rant to go on for pages and pages, but I just want readers to ponder this in the day and age of psychosis and impulsive actions: insurers focused solely on cost and say that we should be using less expensive and potentially more side effect laden older meds to treat illnesses that have much lability and risk for consequences, does a few days, if not outright refusal to access medication have major negative outcomes? And what if an insurer refused Adam Lanza a prescription for an antipsychotic that might taper homicidal thought processes? And then what happened in Newtown might have been prevented?
Ok , not the scenario that is realistic here, but, got ya attention, hmm? I have a patient who is on Concerta, and I am not a fan that med really impacts on Adult ADD with consistent significance, so after meeting with the patient and advising a change to a different formulation of methylphenidate about a week ago, the patient is still without his substitute today. And you know why, because the insurer did not want to pay what is about 10 or so dollars more for Metadate, so held up the script, and then screwed up and authorized Ritalin LA which confused the patient who did not fill it, and now here we are on Thursday night and still no medication.
What if this patient works for a defense contractor and because he/she is not on the ADD med and is either distracted or confused with their job description and does not order the right supplies for the military source accessing these supplies or orders, and then because the ensuing job is not completed, people die, is that not a consequence? By the way, doubt this is what the patient does, but I thought the scenario gets the point across.
Here’s the point: every day, every patient care intervention that is held up solely to save a couple of bucks so the CEO of Medco or Express Scripts can go buy another yacht or mistress another bling item so he/she can make sure Wall Street raises the price of the company’s stock, people are put at risk. And when does outrage and need for accountability finally take center stage?
When it affects you!
Face it, this bullshit of prescription authorization has to have consequences. Maybe someone who is kind enough to spend time reading here sees an opportunity to take action, PLEASE DO! Frankly, I find this intrusion to be beyond reproach. It makes me hope that one day, one of these insurance assholes who defend this process to be in an ER or other health care venue be told himself or a loved one can’t have access to a medication, and then they watch the negative outcome front and center.
I’ll leave you with this term to ponder, not saying much positive about me, but hey, it is what it is:
Schadenfreude i/ˈʃɑːdənfrɔɪdə/ (German: [ˈʃaːdənˌfʁɔʏdə]) is pleasure derived from the misfortunes of others.
That is where I am at these days, not proud of it, but if it teaches people to do better and right, I’ll have my mea culpa moment later. Right now, I just want patients to have the care I was trained to provide.
Not what makes a larger profit margin for a bunch of selfish, indifferent, uncaring jerks in some large office building that politicians gave a tax break to build in the fucking first place.
I’m done.