Insurance Companies Are NOT Psychiatrists--Why Are They Making Decisions?
You have had asthma as long as you can remember--since childhood--and have been seeing the same pulmonologist for at least three years. Your doctor has had you on theophylline, a pill you take three times a day, and a Flovent inhaler (which you use twice daily) for the past year. You went to the pharmacy today and dropped off your scripts, as you do every month, only to be told you can't fill them. Why? Because your insurance company won't approve a prescription for more than 60 theophylline. Nor will they fill a Flovent inhaler for more uses than once daily.
Nevermind your doctor increased your doses two months ago to help you deal with the allergy season, which sends your asthma into overdrive. Nevermind your doctor wrote the prescriptions for the dosage she recommended based on your symptoms and medical history. According to your insurer, because most asthma patients in your sex and age group only take two theophylline a day and use their inhaler an average of once daily, you should be able to get by on the same doses. According to your insurer, you're simply a hypochondriac who's over-medicating and wasting money. So now you're waiting for your doctor's office and the insurance company to work it out, and in the meantime, hoping like hell you don't have an attack because you are completely out of your medications.
Are you furious yet? I am. Because this is exactly what I am dealing with today. When I left my job, we switched to my husband's employer-provided insurance plan, Coventry of Kansas. (Yes, I'm naming names. I only protect the innocent.) Yesterday, I submitted new, handwritten prescriptions for Bob's four medications. Of the four, only two were filled, because he is "over their approved dose limit" for Seroquel and Focalin.
Oh, really? Take me, please, to the genius who made this decision, because I'd like to leave unmedicated Bob with them when his last Focalin wears off this evening. And tomorrow, when the school calls me to come get him, I want that person to go pick him up.
Who are these people who get to decide what medication we take and how much? Not the physicians we're paying $100 (or more) a visit. Why bother going to a doctor at all? Next time you're feeling poorly, just call your insurance company--they apparently have the power to diagnose you AND determine your best course of treatment, all without seeing you OR your medical history.
The good news? My husband's employer is switching to a different carrier (the one my former employer used, in fact). If we can make it through the end of the week, I should (hopefully) be able to get Bob's prescriptions filled as written. And happily tell Coventry of Kansas to kiss my asthma.
ED. NOTE: ConcernedMom (see comment below) agrees with the insurance company and says Bob's psychiatrist and I over-medicating my son. Watch my response: We’re Not Trying to Drug Our Mentally Ill Kids Into Submission (Video)
McClanahan, A. (2011, June 28). Insurance Companies Are NOT Psychiatrists--Why Are They Making Decisions?, HealthyPlace. Retrieved on 2020, July 4 from https://www.healthyplace.com/blogs/parentingchildwithmentalillness/2011/06/insurance-companies-are-not-psychiatrists-why-are-they-making-decisions
Author: Angela McClanahan
Liked Paul's response. We need to put people before profit (it is not about keeping health care costs down). The USA is the highest per capita spender on health care because of the insurance companies.
I have dealt with this issue many times and even the more difficult one, the insurance company's refusal to pay for the drug your doctor has recommended because it is not covered under your plan, or you must only use their "approved" substitute.
This behavior forced me to do some research and what I discovered was amazing. I went to Canadian pharmacies. Lo and behold I found out that not only could I buy with a legitimate prescription any drug that I needed for far, far less money. But, I also found out that the rest of the world, and I mean everywhere, there are generic versions available from reputable manufacturers that are not allowed here in the good old USA.
Case in point--I take the antidepressant Lexapro. Since my insurance company won't approve it, I would have to pay $300/month. In Canada, I purchased the generic version, six month's worth, for $75.00. That's less than the $20.00 copay if my insurance had covered it. There are four other medications I buy in the same way and the savings are even more dramatic.
Now, I can hear the voices--but are they safe? The government has done a marvelous job in convincing people that pharmacies and manufacturers licensed in the USA who sell other medical supplies to thousands of doctors and hospitals nationwide are not trustworthy--hogwash! Also, generics are available elsewhere because the governments require them to be manufactured, period.
Next--but can the companies make enough profit to continue research and development into new drugs? In the words of a Canadian friend who works on the Canadian Prescription Board, "We allow companies at a minimum to make 500 to 1000% profit on drugs they sell here. Do you think that might be enough? Do you think that the company selling Seroquel "wholesale" to a USA pharmacy for $6.00 per pill that sells in generic form "retail" for 35 cents per pill is making enough money, especially when at 35 cents the company is making 500-1000% profit?
"Won't I get in trouble for buying medications in Canada?" The answer is "No" for several reasons. One, it is by law perfectly legal to buy prescription drugs from licensed international pharmacies. Two, I live in South Florida. When the Bush administration was in its heyday and Jeb Bush was governor in Florida, it was tried via Customs to slow the delivery (deliberately) of medications from overseas by holding them at port. Someone sued and that all stopped.
Three, when the state of Oregon decided to buy its medications for Medicaid patients from Canada to save budget dollars, the Fed's sent a cease and desist order. But, guess what, they never followed through...why? The last thing in the world the hugely cash ready drug lobby wants the US public to know is that these prices exist and are legal to buy. So, if the government went ahead with its lawsuit, these details would spread like wildfire over every media outlet and the internet. So, the state of Oregon happily buys its Medicaid medications from Canada and so do I. Over the years, I have saved thousands of dollars and tell everyone I know.
So, don't fret. I haven't met a doctor yet (well maybe one) who hesitated giving me a prescription that I wanted filled in Canada. Even at that, the easy answer is get another doctor, which I did. Sorry for being so long winded, but I get very upset when the American government sells its soul to the insurance and drug companies and a huge section of the American public believes it should stay that way.
I believe our country's healthcare system is more oriented towards economics than it is to the health of its citizens. Your struggle with the insurance company over his treatment is a symptom of how we're failing to take care of our most needy people, our kids.
Have you read MAD IN AMERICA? http://www.amazon.com/Mad-America-Medicine-Enduring-Mistreatment/dp/0465020143/ref=sr_1_1…
After I read that book I made it my goal to go off meds. But, that being said, I am an adult. You, as a parent, have to make difficult choices and decisions re: your child That's what being a parent entails.
Now let's talk about the pharmaceutical companies that have hijacked our mental health system. As one doctor recently told me, don't ever think the drug company CARES. They are all about the money.
And, finally, let's talk about government health care. Statistics show that medicaid/medicare turn down prescription and medical needs much much higher than the private companies. If you do some research, you will realize that since Obamacare was passed (illegally, I might add), costs have skyrocketed, services have been reduced, and covered medications are steadily declining.
Because of all these factors, I, myself, am doing everything possible to be independent of anyone or anything that could have that kind of power over me. Remember, mental illness is "all in your head".
I wish you and your son the best, I really do. But, with the way the government is headed, I fear for the health and well-being of anyone who is not "normal".
What has happened here? Are we remembering drug addiction as with mental illness is a biologically based disease? Just because diagnosis and treatment isn't as easy as diabetes doesn’t make it any less serious. My question to Judy is do you really know how our poorest and sickest Americans live when they "live off of taxpayers’ dollars". It's not a pretty picture. They did not choice to be mentally ill just as an alcoholic or drug addict doesn't "choice" addiction. Perhaps you need to attend some AA or NA meetings to see and hear reality. Maybe you need to visit some subsided housing families and individuals. These are the outlier of our society. And yes, I agree, when the new ACA becomes fully in effect, quality of care goes down the drain. Doctors and Hospitals are money making entities. They do not want patient’s who will hurt their bottom line.
If there's a discrepancy, let the parties work it out on their own time. But the patient's prescription should be covered and filled while this is going on. Certain medications require a time frame during which the levels can be titrated so as to avoid a psychotic episode. I'm sorry to hear you had to experience this.
Money is a huge issue in providing tax payers cash to people who don't work or don't have their own insurance, some poor, sick or just plain not working....When you live off taxpayers dollars, you should be held to some standards as do private care patients. .It is called having a BUDGET... Abuse happens in the doctor's office and you can't .prevent it, just keep it to a minimum. Don't be rediculous and infringe on my rights while trying to prevent abuse in the medical field.
I agree there is something about drug addicts. They get way too much coverage than people with other addictions. or conditions...And people with other mental health diagnosis' don't get. Why? I think it must be a federal mandate....insurance companies and state facilities may be forced to provide this long and protracted care, costing tax payers millions of dollars. Maybe it is politically correct to have all this money directed at addicts and money taken from other treatments....
All doctors know they can request waiver to requirements or restrictions as long as they can support it. I've worked with insurance companies and even the government has these restrictions. Face it, they are there to keep costs down and to prevent abuse.
@Herb--I understand the restrictions are there to keep costs down and prevent abuse--however, and call me socialist if you wish, why must money be an object when someone's health is at issue? consider the cost of untreated mental illness and ask if it's more or less than the difference between name-brand and generic medications. beyond that, although the intent may be to "prevent abuse"--the only people who can't get their drugs are people like me and my son who are legitimately trying to get them for their intended use at their intended dose. Addicts rarely have problems scoring what they need.
it is amazing that some insurance companies consider antiepileptic drugs uncovered item and needs an approve from the company to be dispenced so will the seizures of an epileptic patient wait for this approve
Justs wait until we get this new government health care. We will be so restricted in the benefits for mental disorders. Mental health providers will not like working for the government. The only reason they take government programs now is that they have private patients that cover the cost of the low government reimbursements. Actually that is true for all doctors. You can't afford to take care of only government people, like the medicare and medicaid people. So if you think mental health treatment is wanting now, you haven't see anything. There will be three people standing a the approval gate.....
All you have to do is go to a state facility and use tax payer's money and you can get any medication you want no matter what the cost. My own insurance company makes the drugs they get almost out of anyone's budget...$10.00 a pill!!!!!! But private insurance has sorely under-represented the mental health needs of people and pays their doctors so little that... no one with insurance can see a mental health provider unless you pay cash for the visit. It isn't covered nearly as good as medical. Major mental disorders are medically based this day and age. If several of our child murderers had been able to see a mental health therapist as often as they needed, maybe Columbine never would have happened!
Holy smokes! the old saying about walking in someone else's shoes holds true. A while back I was taking many psychotropics which I doubt I would have lived without at that time. My insurance company recently stopped reimbursing for one of those medications. They also refuse to pay for an asthma medication.
I hope that Bob and his mom do OK and that the ins. company pays for the proper meds.
Even if the people making these decisions were physicians, no doctor worth their salt would prescribe a medication without seeing or even so much as talking to the patient or getting a complete history. If a community doctor did that and got caught,would they not be brought up on ethics charges, or, if something went wrong as a result of doing this, malpractice? These insurance companies seem to be untouchable because their power lies with the amount of dollars they bring in, not the lives they save.
They r not your dr. Your dr knows u best! My ins co made me try 2 other meds b4 paying for abilify and now still won't pay 4 it!
@anonymous--I agree 100%. even our "new" plan, which i started reviewing last night, HEAVILY pushes their "tier 1" drugs. as if to say, "you don't need effexor, you're just a prima dona who thinks she needs the expensive stuff. why can't you just take good ol' cheap sertraline like everyone else?" it's insane. pun not intended, but fitting.
Concernedmom is taking a generalized opinion and applying it to a specific case. That is almost always a dangerous way of responding. In general, statistically, there is a good argument that, as a society we are over-medicating our children. And our adults. But psychiatric medications control symptoms, which is both their blessing and curse. For children, who really really need to have symptoms controlled in order to do their tasks as children and in order for the adults around them to guide them through childhood, under-medicating is much more dangerous than over medicating. And after just a few readings of your wonderfully honest posts, I think there is not doubt that you are expressing valid and validating opinions. And doing the right thing for you son and family.
From age 14 to 24 my son survived only because of cocktails of pysch meds. Now, as an adult, he is just beginning to think of how to reduce them.
When my insurance company approves narcotics for my migraines but not the non-narcotic medications I wonder if there is any reasoning beyond saving money.
I hope your new insurance works out for you and your family!
Amazing lack of insight @concernedmom. But that's not important.
I was working with my doctor on a treatment plan and was told by my insurance it was good enough & they would not cover me for my disability claim despite med records supporting my actions. Separately they approved almost 250$ in private physical training.
1/ It was mental health I needed treatment for and they would not approve bc my plan was not in line with their preference. But they can pull 250 out for something not directly related to my illness? Huh?
2/ I could not afford the treatment I needed because they would not approve my claim.
Seriously major problems in our society when bureaucracy rules over common sense and imperaonal corporations have more rule over our health than our health care professionals. What an impossible job good practitioners have.l
I'm sorry you are having problems with your insurance company. Th docors should decide what medications each person needs and cover it. I can see if it is to soon for a refill, but I don't think that is your case. I hope he can hold out until your new insurance kicks in.
Concernedmom--I am grateful that I am not left completely speechless by your asinine comment because I want to make sure that you realize how asinine your comment was. I will not break down your comment to point out each and every fallacy. I ask that you please think before you voice your thoughts on anything, especially how other people raise their children. And medicating? Do you know what asthma is? Do you know Bob's history? Please practice writing in your diary before you comment on blogs again. Please.
How does a child so young in the prime of his development take four different medications? How is it legal? Sounds overmedicated to me. The medication causes so many problems, health and otherwise. What psychiatrist allows this? It is unethical any way you slice it. How would you possibly know who Bob is with all those meds in him!? If that's what it takes to keep him in school, you may want to consider taking him out, or switching schools. Insurance company is right this time, I'd say. Too much is too much--I don't care what the diagnosis.
Have you READ any post in this blog (or anyone else's blog on this site) other than this one?
Because I have to truly wonder based on your comment.
And sadly, I'm sure you'd probably be the first concerned parent to (1) demand my son be removed from his school, (2) point the finger at me as being to blame for his behavior, and (3) sue me and the school district for damages after unmedicated Bob tries to stab your child with a pair of scissors for no reason, other than that your child was making a noise Bob found irritating and refused to stop after Bob asked him.