Insurance companies and “health care coordinators” are increasingly insinuating themselves into the care of patients. While we are all accustom to generic substitutions as a cost saving measure, you may not be aware that a pharmacist of CareFirst is “working with primary care physicians” to review cost effective medication treatments when the cost of current medications are higher then insurance companies want to tolerate.

In my case, I received a call from Samantha, a pharmacist from CareFirst, to discuss my patients medications “to see if there were other options”. My patient is a woman in her early 50s with severe depressive episodes of crying repeatedly everyday, highly anxious, not leaving the house without a companion, and thoughts about her death (she is not terminally ill). We have been seeing each other for several years with periodic remission of symptoms lasting months. Nevertheless, she is on a complex regimen of psychiatric medications to achieve some level of relief, although not complete. Not working, she lives with her supportive husband, daughter and her husband.

When I called and spoke with Samantha, she suggested that I consider tapering and stopping her Latuda while increasing her seroquel. Interesting suggestion but what was the basis for the recommendation? Did she have information on the patient’s current symptoms? NO. Did she have information on the history of this woman’s depressions? NO. Did she know the level of suicide risk of this patient? NO. Did she know the history of psychiatric medication trials? NO. Did she know the side effects experienced by the patient with certain medications? NO. Did she know the patient’s medical conditions that effected psychiatric medication choices? NO. So what was the basis of her recommendation? “…for cost saving and optimizing treatment…” Here is the answer: Latuda is a costly medication as there is no generic, while seroquel is less costly in its generic form. Both drugs have FDA approval as additive agents to antidepressants for the treatment of depression.

I informed her that her recommendations without any clinical information about the patient had no relevance to me. And frankly, if I were to make and institute medical decisions without adequate clinical information, I’d be liable for malpractice. While it is appalling to me to see such “conversations” with physicians or any health care prescriber as standard operating procedure for insurance carriers, it is twice as infuriating to realize that patients have no idea how their care is being influenced.

So, the next time you see your doctor, ask them “Has my insurance company contacted you about changing my medications?” In the end, your physician has a far greater interest in your health than your insurance company.

I will continue to blog about ways in which insurance companies justify their procedures while patients suffer with suboptimal care and outcome.

David W. Goodman, M.D., FAPA