Tuesday, November 17, 2009

When your insurance company makes medical decisions for you...

Ok, so here's the scenario... wait, let's make it generic (oooh there's that word again)

Patient X has medical condition Y.  Doctor A prescribes medication P to patient X because it's the medication best suited for condition Y.  Medication P is not available in generic form because it is kind of new and the company that makes it has managed to hold onto the patent (wait, the military has access to a generic form... but it is not available to consumers...).  Patient X takes this medication successfully for several years.  Patient X's medical condition is ameliorated and their quality of life is significantly higher than it was without medication P.

Along comes Aetna, and they decide that this happy little scene is too expensive. 

Patient X goes to doctor A and explains that prescription benefits in Aetna's plan are changing and will severely impact patient X's ability to afford health care.  Doctor A reviews the patient's medical file and says to patient X:

"Ok, so we tried drug R (available in generic) and that didn't work for you.  How many years have you been taking medication P?"

"3 years," says patient X.

"And what is it that Aetna wants you to take instead?' asks doctor A.

"Drug D, which is available in generic," answers the patient.

Doctor Y scratches his chin and reviews the information about drug D in his PDA-thing.  It turns out that he has never prescribed drug D for patients with condition Y.  He reviewed the patient's medical file.

"Well, i am somewhat hesitant to go from a medication that we know works to a medication that hasn't been widely prescribed for this condition in decades," says the doctor to the patient.

Patient X is flustered: "My monthly prescription costs will more than quadruple if I stick with medication P, which is considered 'nonformulary.'  And I fear it will be worse next year because trends suggest that nonformulary drugs will cost patients more and more each year until they are phased out (in terms of coverage) altogether.  I don't want you to prescribe a medicaiton that you have concerns about, but couldn't i try it just to see if it works?"

Doctor Y can see how concerned the patient is.  "This medication is somewhat different than what you've been taking.  It can't be mail ordered.  It's what they call 'Schedule 2,' which means it is highly regulated (by the DEA).  You will have to see me once every four to six weeks for me to check how you're doing.  You will need to take your blood pressure regularly.  If you have heart palpitations, high blood pressure, or any unusual side effects, you will need to let me know immediately.  I will give you a list of what to look for.  What you had been taking was a 'Schedule 4 medication' so this will be a different experience for you. But we can give it a shot.  If i judge that it's not the appropriate medication for you after this trial period, i will put you back on medication P, though."

"I understand," said the patient, carefully considering what the doctor just said.  The patient was puzzled because it seemed as thought the savings accrued by Aetna by having this generic drug prescribed as opposed to the nonformulary drug would be offset by the new requirement to see this specialist about once a month (with medication P the doctor checked on the patient once or twice a year.) 

The moral of the story is Aetna knows best.  The powers that be at Aetna are determining how medical conditions should be treated.  To hell with medical degrees.  After all, doctors don't know best, Aetna does!

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