Newest Insurance Outrage

While I am on the topic of bad behavior by insurance companies, check this out:

A preteen girl in my practice needed antibiotics for a urinary tract infection.  The antibiotic was chosen based on the sensitivities reported by the lab (this means I was choosing an antibiotic to which this child's bacteria was know to be sensitive).  Of all the choices, I chose the antibiotic with the least side effects, which also happened to be one that has existed for quite a while and therefore has a generic version.  In the real world (meaning the world in which someone pays the pharmacy directly for their medicine at the full price), this should be the cheapest medicine.

So, I am practicing really good medicine here, right?  I chose the cheapest antibiotic with the fewest side effects, and I know from the culture that this medicine will work.

To borrow from Lee Corso:  Not so fast, my friend.  The insurance company, who will remain nameless, apparently doesn't have a special deal with the maker of GoodCheapMed, so they deny the med.  Unfortunately for the child, the insurance company decides this at 6:45 p.m. on Friday evening and notifies us by fax only.  No call to the on call physician for the weekend.  No call to the off call, but prescribing, physician.  The only notice is by a fax to an office that the insurance company KNOWS will be closed until Monday.  The child then goes the entire weekend without an antibiotic because of the misbehavior of her insurance company.  The situation is discovered on Monday and the child receives a different, but still effective, antibiotic and finally receives the needed treatment.

Two general lessons from this story:
1.  Do not EVER think that your health insurance company cares about your health.
2.  If your doctor prescribes a medicine for you that gets denied, call your doctor (even if it is the on call doctor) so that they can address the situation.

Insurance Company Logic: Reject First, Then Overdose

I have not often talked about the myriad ways that insurance companies interfere with the practice of good medicine, in part because I don't have enough time to recount every story.  I had an infuriating dealing with a company this past week, though, that I think speaks volumes.

The short story is this:  The patient is a two-month-old breastfed baby with gastroesophageal reflux which has not been controlled with "reflux precautions" (feed smaller volumes, burp well, keep upright after feeds, and elevate head of bed to 30 degrees) or with Med A.  Med B has a number of negatives as an alternative or adjunctive medicine, so the next most appropriate medicine is Med C.

Since this is a young infant, I prescribe a dose appropriate to the baby's size and, surprise of all surprises, the insurance company denies the prescription because it will cost them more money.  Never mind that it is the appropriate medicine at the appropriate dose in an appropriate form for an infant.

So, what is the insco's reasoning?  The patient must first try OTC Med C.

Oh, you say, that's not so bad.  Shouldn't patients try OTC meds first anyway?

Well, maybe in some situations, but the OTC med in this situation would be a dose about 8 times higher than the patient should have (and would require the two month old to swallow pills).

To bypass the INSURANCE COMPANY'S RECOMMENDED OVERDOSE of my infant patient, I have to spend my time waiting on hold with the insurance company, so that I can eventually talk to their employed physician, who does not actively practice medicine and is most likely not a pediatrician, and try to convince him or her that it is bad medicine to overdose my patient.

Oh, the joys of practicing medicine in the U.S.