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Theres a third party in the exam room

MY VIEW: Patients lose as insurers increasingly pit money against medicine

Insurers have become so intrusive into the practice of medicine in Oregon that they might as well just sit down in the exam room, right next to the doctor.

A few weeks ago I was seeing a man suffering from schizophrenia. He was unhappy with his medications, which he thought were making him tired and depressed.

He wanted off one particular drug - a decision that would have been disastrous. If he stopped that drug, he probably would just get much more ill. Fortunately, he agreed to continue with the medication under the stipulation that we also would discuss using a stimulant to increase his energy.

This was dicey. Stimulants, such as Ritalin, can increase the delusions that are characteristic of schizophrenia. However, this young man had been given such drugs in the past and did well.

After several visits spent discussing the alternatives, he and I agreed. We would try him on what seemed to be the safest of the stimulants. For this particular drug, we would be prescribing 'off-label.' I wrote a prescription.

When a doctor prescribes off-label, it means that the doctor is using the drug for some purpose other than what it is marketed for. The doctor does so cautiously, with the knowledge and consent of the patient. Off-label prescriptions are common. According to a recent study, about four of every five prescriptions written by psychiatrists are off-label.

The next day, I received two faxes and a phone call from the patient's pharmacy. Later, I also got a call from the patient. Apparently, the patient's insurance was refusing to pay for the drug until I first obtained their consent. One month of the medication would cost my patient $400 without insurance and, thus, was prohibitively expensive.

I called the insurance company, and they faxed me a pre-authorization form. I filled it out and faxed it back. I heard nothing more until, a week later, my patient came to his appointment, hallucinating and psychotic.

Apparently, his insurance had rejected the pre-authorization and did not notify me. Sabotaged by his insurer (and, I might add, influenced by reruns of Tom Cruise badmouthing psychiatric medications), my patient had abruptly stopped his critical medication.

Insurance companies are increasingly making medical decisions, many of which are downright bad. They are making it burdensome or impossible to use specific medications. They are telling doctors what dosages of medications the company thinks are appropriate. Worst of all, many are not allowing treatments that are prescribed exactly as the FDA approved them.

Recently a surgical treatment for life-threatening, chronic, treatment-resistant depression was FDA approved. However, despite the federal approval, many insurers will not cover it.

As of this month, about 3,100 people nationwide have sought preauthorization for this treatment. About 60 percent of these patients have been told 'no' by their insurance. For the lucky few that actually got clearance, it took around two months just to get the insurance approval; the patients still had to then schedule the surgery.

A two-month wait for severely depressed patients?! That is obscene.

Why do insurers reject or delay treatment? They will talk statistics and epidemiology, but the real reason is simple; the surgery is expensive. They claim they do this for 'quality control,' but it is motivated by money, plain and simple.

Insurers are not being upfront with patients. When signing up to a health plan, they claim to cover all sorts of maladies. But, behind closed doors, they obstruct treatment to reduce costs.

By all rights, insurers should be sued for the harm they cause. However, because of current law, that rarely happens. In Salem, we need to change that law.

In the meantime, patients and doctors should appeal every medication and treatment denial, to the fullest extent allowed. If insurers insist on second-guessing doctors, they must be made to feel the financial consequences of providing substandard care.

Jerald Block is a board-certified psychiatrist in downtown Portland and teaches at Oregon Health and Science University.