What standards do insurance companies hold themselves to?

My newest iteration of a VIP, or very ill patient, is a lovely middle-aged gentleman who has been sick for a year with a multisystem disorder. It started with severely swollen hands and feet along with significant anemia and fatigue. One year, many imaging studies, a couple of biopsies, and a latent tuberculosis infection later, he is still very sick. Throughout his ordeal he has often said to me: “You are the quarterback.” I’ve taken that to heart.

I don’t know why this surprises me, but insurance companies are being increasingly difficult. They’re passing more of the cost of health care to patients, and they’re less willing to cover medications and procedures. I have patients who can’t get physical therapy because they can’t afford the $45 copay for each visit. One patient stopped her hydroxychloroquine because it went from $4/month to $90/month. A couple of patients have opted not to take risedronate because the copay per month is $200 – that’s $200 for one generic pill.

At a recent morbidity and mortality conference, the attendees, nonrheumatologists all, were incredulous that cyclophosphamide, which has been around for ages and should be generic, is not covered by Medicare. Our patient with granulomatosis with polyangiitis and alveolar hemorrhage was on the hook for several hundred dollars per month, which he couldn’t afford.

Insurers also have been giving me more pushback for medications. For example, I recently tried to start one of my patients on etanercept for rheumatoid arthritis. His insurance company wrote to say etanercept was not their “preferred” first-line biologic. I explained that their preferred anti-TNF agents all carried the potential for developing anti-drug antibodies when used without methotrexate, which was contraindicated in my patient. They were unmoved.

I had a similar experience with my VIP. He was denied tocilizumab because he had not yet tried and failed two anti-TNF agents. I appealed the decision because I thought etanercept had caused a side effect that might be a class effect. To my surprise, rather than getting an approval, I received instead a request for medical literature to support my theory. Who knew that the decision-bots were so sophisticated?

Ultimately, I got the drug approved, but of course this process was an inconvenience to me, adding unnecessarily to the work of doctoring. More importantly, it was time wasted for my patient who was suffering tremendously.

My point is this: The idea of me as quarterback is quaint. Ultimately, it is the insurance company that dictates testing, treatment, physician, and facility.

There is an expectation that physicians are perfect, and we have internalized that expectation to some degree, holding ourselves to exacting standards, guided by what’s in the patient’s best interest. I want to know what sort of standards insurance companies hold themselves to, because I think they – out of all of us involved in health care – they who have the greatest resources should be absolutely unimpeachable.

Dr. Chan practices rheumatology in Pawtucket, R.I.

My newest iteration of a VIP, or very ill patient, is a lovely middle-aged gentleman who has been sick for a year with a multisystem disorder. It started with severely swollen hands and feet along with significant anemia and fatigue. One year, many imaging studies, a couple of biopsies, and a latent tuberculosis infection later, he is still very sick. Throughout his ordeal he has often said to me: “You are the quarterback.” I’ve taken that to heart.

I don’t know why this surprises me, but insurance companies are being increasingly difficult. They’re passing more of the cost of health care to patients, and they’re less willing to cover medications and procedures. I have patients who can’t get physical therapy because they can’t afford the $45 copay for each visit. One patient stopped her hydroxychloroquine because it went from $4/month to $90/month. A couple of patients have opted not to take risedronate because the copay per month is $200 – that’s $200 for one generic pill.

At a recent morbidity and mortality conference, the attendees, nonrheumatologists all, were incredulous that cyclophosphamide, which has been around for ages and should be generic, is not covered by Medicare. Our patient with granulomatosis with polyangiitis and alveolar hemorrhage was on the hook for several hundred dollars per month, which he couldn’t afford.

Insurers also have been giving me more pushback for medications. For example, I recently tried to start one of my patients on etanercept for rheumatoid arthritis. His insurance company wrote to say etanercept was not their “preferred” first-line biologic. I explained that their preferred anti-TNF agents all carried the potential for developing anti-drug antibodies when used without methotrexate, which was contraindicated in my patient. They were unmoved.

I had a similar experience with my VIP. He was denied tocilizumab because he had not yet tried and failed two anti-TNF agents. I appealed the decision because I thought etanercept had caused a side effect that might be a class effect. To my surprise, rather than getting an approval, I received instead a request for medical literature to support my theory. Who knew that the decision-bots were so sophisticated?

Ultimately, I got the drug approved, but of course this process was an inconvenience to me, adding unnecessarily to the work of doctoring. More importantly, it was time wasted for my patient who was suffering tremendously.

My point is this: The idea of me as quarterback is quaint. Ultimately, it is the insurance company that dictates testing, treatment, physician, and facility.

There is an expectation that physicians are perfect, and we have internalized that expectation to some degree, holding ourselves to exacting standards, guided by what’s in the patient’s best interest. I want to know what sort of standards insurance companies hold themselves to, because I think they – out of all of us involved in health care – they who have the greatest resources should be absolutely unimpeachable.

Dr. Chan practices rheumatology in Pawtucket, R.I.

My newest iteration of a VIP, or very ill patient, is a lovely middle-aged gentleman who has been sick for a year with a multisystem disorder. It started with severely swollen hands and feet along with significant anemia and fatigue. One year, many imaging studies, a couple of biopsies, and a latent tuberculosis infection later, he is still very sick. Throughout his ordeal he has often said to me: “You are the quarterback.” I’ve taken that to heart.

I don’t know why this surprises me, but insurance companies are being increasingly difficult. They’re passing more of the cost of health care to patients, and they’re less willing to cover medications and procedures. I have patients who can’t get physical therapy because they can’t afford the $45 copay for each visit. One patient stopped her hydroxychloroquine because it went from $4/month to $90/month. A couple of patients have opted not to take risedronate because the copay per month is $200 – that’s $200 for one generic pill.

At a recent morbidity and mortality conference, the attendees, nonrheumatologists all, were incredulous that cyclophosphamide, which has been around for ages and should be generic, is not covered by Medicare. Our patient with granulomatosis with polyangiitis and alveolar hemorrhage was on the hook for several hundred dollars per month, which he couldn’t afford.

Insurers also have been giving me more pushback for medications. For example, I recently tried to start one of my patients on etanercept for rheumatoid arthritis. His insurance company wrote to say etanercept was not their “preferred” first-line biologic. I explained that their preferred anti-TNF agents all carried the potential for developing anti-drug antibodies when used without methotrexate, which was contraindicated in my patient. They were unmoved.

I had a similar experience with my VIP. He was denied tocilizumab because he had not yet tried and failed two anti-TNF agents. I appealed the decision because I thought etanercept had caused a side effect that might be a class effect. To my surprise, rather than getting an approval, I received instead a request for medical literature to support my theory. Who knew that the decision-bots were so sophisticated?

Ultimately, I got the drug approved, but of course this process was an inconvenience to me, adding unnecessarily to the work of doctoring. More importantly, it was time wasted for my patient who was suffering tremendously.

My point is this: The idea of me as quarterback is quaint. Ultimately, it is the insurance company that dictates testing, treatment, physician, and facility.

There is an expectation that physicians are perfect, and we have internalized that expectation to some degree, holding ourselves to exacting standards, guided by what’s in the patient’s best interest. I want to know what sort of standards insurance companies hold themselves to, because I think they – out of all of us involved in health care – they who have the greatest resources should be absolutely unimpeachable.

Dr. Chan practices rheumatology in Pawtucket, R.I.