With each passing year, insurance companies are instituting contractual clauses in benefit packages that restrict psychiatric medications for patients. Specifically, this comes in the form of prior authorization for stimulant medications, despite FDA approval of these medications for ADHD. Combine the prior authorization process with changes in drug formularies (a tiered list of  medications that an insurance company will authorize) and you end up with a series of hoops to jump through. For doctors, this is an increasing administrative burden on staff to get authorizations for patients who desperately need their medication. With each insurance company having their own process, it becomes impossible for doctors’ offices to keep track of how to process this information. The unnecessary delays can leave patients without medication and treatment.

On the occasion that a patient requires medication dosing outside the PDR’s dosing guidelines, the pro forma initial authorization denial leads to submitting paperwork for an appeals process. Were the appeals process above board and transparent, I’d have no problem but the conflict of interests abound and patients are denied medication and dosing that had previous worked well.

In the appeals process, the patient’s case is assigned to an “independent” medical reviewer. This may be a physician or, in some cases, a pharmacist. The physician reviewing the appealed case is, in my experience, not an expert in the disorder or medication dosing being reviewed and therefore has very limited insight from which to review the specifics of unusual dosing for, say, a rapid metabolizer. In addition, they are often unfamiliar with relevant research supporting the unusual but appropriate dosing, instead relying on FDA recommended dosing.

The reviewer’s reliance on FDA recommended dosing may serve several purposes:

1. FDA dosing gives their opinion legitimacy;

2. If the insurance goal is containment of expense, an appeal denial by the reviewer serves the insurance company goal;

3. If the review’s income is dependent on triaged work from the insurance company, the reviewer has a conflict of interest. If he finds in favor of the patient’s treatment, the insurance may stop assigning work to them;

4. If a reviewer’s recommendation favors of the patient’s medication and dosing, the insurance company is not obligated to follow the recommendation and can triage the review to someone more favorably disposed to the company’s goal. It is important to know that the reviewer’s recommendations are confidential and will not be conveyed to the treating physician who discusses the case with the reviewer. Transparency and good faith seem not to be part of this process.

5. While the insurance company sites its concern for patient safety in their letters to patients, the doctor-patient relationship is compromised if the patient comes to believe from the insurance company that the doctor is “over medicating” the patient;

6. The reviewer can request double blind placebo controlled trials of higher medication dosing knowing that such research doesn’t exist because pharmaceutical companies don’t typically investigate the research question “if the patient doesn’t respond optimally to a dose, would they respond to higher doses?” And so without the controlled trial to report to the insurance company, they can easily deny the dosing, despite the fact that the patient had been on the higher dose for 2 years with benefit.

This circumstance typically occurs when you change a policy or carrier and this dosing is denied. Although insurance companies often cite their concern for the patient’s safety if dosing is higher than noted in the PDR, this doesn’t make medical sense if the patient responses well, blood pressure/pulse are normal, and there are no problematic side-effects. Therefore, under the guise of concern for the patient (as if the doctor is being cavalier in dosing), they make medication decision for economic motives. While I understand the need to contain the expense of medications for their budget, patients suffered needlessly and their productivity is reduced, sometimes leading to job loss and/or divorce.

In my next blog, I will give a specific example of how this process has compromised my patient’s treatment leaving them with impairments from persistent ADHD symptoms. In the next blog I will refer to a specific company and reviewing physician who, in my opinion, demonstrate the reality of the above 6 issues I highlight. I will also give you very specific actions that patients can take as advocates with their doctors to secure their effective treatment.

David W. Goodman, M.D.