Physician Frustrated in Efforts to Prescribe Critically Necessary Medications

In today's post, our guest blogger, a local primary care physician, sounds off on a bureaucratic nightmare and the potential harm to patients:

I am a primary care physician and have been practicing in Cambridge for nineteen years. There are many challenges and frustrations for physicians attempting to provide the best possible and safest office based care to patients. However, never before have I felt more outraged by the unnecessary potential and actual harm and suffering some of my patients have had to endure with the introduction of many of the individual insurance programs that were created by the relatively new Medicare Part D program. Some of these programs are completely unscrupulous in their limitations to essential medication.

Here is one example:
One 63 year old man who has multiple medical problems including diabetes, hypertension, heart disease and decreased kidney function has been fairly stable in recent years, but close to needing dialysis in spite of our best efforts to hold that off with medications. There are many clinical guidelines and studies that support the use of one of his medications (losartan, of the class of medications called “ARB’s) to protect his kidneys and stave off dialysis in the situation he is in (He is unable to tolerate first line medications called “ACE I”). He had been on this pill along with many others for many years. When his insurance was switched to Health Net Orange, one of the 15 or so Medicare part D programs approved to practice in the state, they denied him use of this medication or any alternative in the class. They offered no explanation except to say that it is not formulary. After reapplying a couple of more times and being rejected I called the company myself, hoping to reach a medical reviewer, even the Medical director to explain my rationale for the necessity of this medication. After literally 2 hours of calling, getting put on hold and being transferred, this physician had only spoken to various clerks, and gotten no useful advice. Further calls by the office manager were equally unfruitful. Finally the only way the medication was approved was when I referenced in my clinical notes that I felt that this medication was necessary to prevent complete renal failure which would lead to lifelong dialysis, stroke or heart attack, and that in spite of my best efforts to get the medication approved, his insurer would not do so. I further went on to say in the record that I felt the insurance company should have some responsibility if one of these untoward events occurred while off his medication! I have never written anything referencing any insurance company in a record in my entire career, and might have considered it unprofessional before this, but my patient’s health was at stake and I couldn’t think of any other way to try to get the medication approved.

I sent a copy of this note to the insurance company with the fourth medication request and after about 6 person-hours over a 3 week period of time trying to get this medication approved, it was miraculously approved the very next morning until the year 2039!!

It infuriates me to see patients put at unnecessary risk like this, and it is exhausting the precious resources of primary care practices. Think of the cost of this occurring dozens or hundreds of times per year probably in every office in the state and the harm that undoubtedly has come to easily thousands of patients per year! This is not the only insurance carrier that commits this disservice; but some the Medicare part D carriers are very much more inclined to this sort of practice than the HMO’s and traditional carriers in the area and even much more so than Medicaid and the newcomer Commonwealth Care, in my experience. I write this to help give a voice to practitioners struggling to do their best for their patients in this arena and to let patients know about this threat to the safety of patients that is very real and has disempowered practitioners to get their patients medications they need. I am looking for ideas how to find ways to make these carriers more accountable to patients in the basic area of necessary medications.