The Minneapolis...Or Is It Hartford?...Two-Step

Conjure yourself as a wallflower: You are a shy early-adolescent compelled by your parents (who at all times adhere to the operative cultural norms) to attend your first dance.  You would rather not be there at all.  Your life as it was was perfectly acceptable.  You were happy with the old, self-sufficient ways.  But now, along with your peers, you are entering a new phase.  From now on the world will work dyadically.  More and more, you will be required to operate in conjunction with a second party.  And this second party, in many respects, is not sympatico. Its motives and methods and  do not always align with yours.  Yet still you hope for the best...

Bring up the music, turn down the lights - the moment has arrived.  Your expectations are shaped by what you believe you are owed: a polite and respectful pairing; civility, if nothing else.  Instead you are greeted with a rude awakening.  Your partner is an arrogant lummox, indifferent to your sensibilities. While the band plays waltz music you are dragged through a lumbering bump-and-grind.  In the process your hair is mussed, one foot is mashed,  an earring is dislodged. What's worse: at the end, there's no apology, no acknowledgement of the brutishness of what has just transpired; indeed, you are quite convinced that you are not alone - you are merely the first of many hapless victims for that evening alone.

Welcome to the rhythms of "step therapy," yet another barbed arrow in the quiver of managed care, still seemingly in ascendency, a galling procedure whereby "prior authorization" for a prescriber's first choice of medication is "denied" until such time as (usually two) "preferred alternatives" from an insurance company's formulary have been tried and have proven either ineffective or intolerable.  I had thought it insult enough that patients be required to "fail" two trials of medications with inferior clinical profiles (e.g., adolescents in my psychiatric practice are now "required" to try two generic stimulants whose short or intermediate duration of action is guaranteed to leave them without any therapeutic benefit during the second half of the school day - unless, that is, they wish to submit to the stigma of presenting to the school nurse every day for their "stupid pill" - before they can receive the long-acting medication that is the standard of care recommended by the American Academy of Child and Adolescent Psychiatry) before gaining access to what, from the beginning, simple common sense held to be the proper choice.  Despite years of steeling myself to callousness of the managed care organizations, I was nonetheless appalled by my most recent encounter with step therapy requirements, since the process has been rendered EVEN MORE LUDICROUS by the inventive touches of faceless executives bent on achieving promotion, I would wager, through demonstrations of their ability to concoct ever more sociopathic obstructionistic schemes. Consider this excerpt: A new patient presents to my practice, having moved to Rhode Island from a different state.  For a year or more, she has been taking Strattera, with good results, for her ADHD, having experienced adverse effects from previous trials of methylphenidate and mixed amphetamine salt preparations.  In conjunction with her move, however, her health insurance has changed. When the first prescription for Strattera reimbursable under the new plan is presented to a Rhode Island pharmacy, a prior authorization form is faxed to us by the insurer.  The PA asks for documentation of failures on two formulary drugs, a condition which the patient's clinical history does satisfy.  My office submits the PA form, properly executed.  Several days later, we receive notification that the PA request has been denied, because, in the standard boilerplate, the Strattera is not "medically necessary."  I then instruct my office manager, as I do quite frequently these days, to request a "peer to peer" review in appeal of the decision.  More time passes.  Finally, I am called by a retired (probably on the basis of "burn-out," if he has had many such experiences as I am relating) psychiatrist NOW EMPLOYED BY THE INSURER (no conflict of interest there!).  After a little perfunctory back-and-forth, he informs me that the denial will have to stand because, as I have failed to note in the fine print, treatment failure with the formulary alternatives did not occur IN THE LAST SIX MONTHS.  My efforts to cajole him into a different opinion through the use of logic fail.  His decision is firm.  In essence, I am told: IT DOESN'T MATTER THAT THE FORMULARY PRODUCTS WERE ALREADY TRIED AND PRODUCED ADVERSE EFFECTS.  IF YOU WANT THIS PATIENT TO RECEIVE REIMBURSEMENT FOR STRATTERA UNDER OUR PLAN, WE WILL REQUIRE YOU TO AGAIN GIVE THE PATIENT MEDICATIONS WHICH, AS THE PATIENT HAS TOLD YOU, PRODUCED ADVERSE EFFECTS.  End of conversation.  Click.

Expletive deleted.

How will the story end?  Happily, I predict.  The reason being that I will prescribe one tablet of Ritalin to the patient and, then, one tablet of Adderall.  The patient will be instructed to fill each prescription in sequence, and then flush each tablet down the toilet.  The insurer's preconditions will thus be satisfied and the patient will be able to use their insurance benefit.

At least two lessons, it seems to me, can be derived from this anecdote.  Number one: the chaperones have failed at their task.  Which is to say, WHERE ARE THE INSURANCE REGULATORS?  How can this kind of grossly manipulative, illogical protocol be allowed to exist?  And sadly, number two: PLAYING THE SAME KIND OF MENDACIOUS LITTLE GAMES THAT THE INSURANCE COMPANIES PLAY OFTEN IS THE ONLY ETHICAL COURSE OF ACTION.  And so it goes - two-stepping with the Leviathan.

Is Care Delayed Tantamount to Care Denied?

Justice delayed is justice denied, as the saying goes. By the same token, does it not hold that treatment delayed is treatment denied? And thus are not risks increased, treatment outcomes compromised, sufferings magnified?

Call me Ishmael. My partners and I operate a large psychiatric practice on the outskirts of a mid-sized Northeastern city. Our patient population comprises a representative spectrum of the local community, from early adolescents on up. Within our specialty, we are the face of American healthcare. Among the many machinations concocted by the managed care entities through the years, we suspect that a new one has recently been given birth. It might well be dubbed “managed delays.”

In the good old days of insurance company SOP, especially among the for-profits, this would have referred to the scheme of requiring “doctors or doctor representatives” to call a deliberately understaffed toll-free number and proceed through a three-or-more step process (including built-in hold times, needless recitations of patient demographic information, a rotating menu of inane questions posed in robotic tones by first-name-only drones hunkered down in underground cubicles at the opposite end of the continent) to obtain “prior authorization” for anything other than generic Motrin. Recently, however, we have seen evidence of a new and more pernicious form of obstructionism: Properly formatted and completed prior authorizations requests simply go unanswered for as long as THREE WEEKS after they are faxed to the insurance entity. Duplicate requests go unheeded. Follow-up phone calls – if we can actually determine which call center to contact - do not accelerate the response. Generics receive no better response than brand-name drugs. We are forced to conceive of a system whereby only those facsimiles which have thoroughly yellowed at the bottom of the “in” box on the desk of the one remaining employee in the PA department are answered. More than ever, the profit motive seems alive and well.

We suspect that this variant form of industry unconscionableness is so new that the plaintiff’s bar has not yet had time to mine it for a potentially lucrative strike. Indeed, a recent search of the LexisNexis database using the keywords “prior authorization” and “delays” failed to find any evidence of relevant case law at the appellate or state supreme court level. Nonetheless, the number of injuries that might be suffered as a consequence of such delays is likely to be substantial, not only within the province of psychiatry, but across the landscape of medicine. That they would, in turn, be actionable is predicted, among other sources, by the American Bar Association Family Legal Guide (viz. http://public.findlaw.com/abaflg/flg-17-2a-9.htm), which states that “…consumers can sue an MCO [managed care organization] for injuries resulting from the company’s refusal to authorize medically necessary treatment.” The defense, in such an instance, would doubtlessly argue that authorization was not refused – simply delayed. To this we would suggest the following syllogistic rebuttal: If a delay is a denial, and a denial is a refusal, then a delay is a refusal. And even if it is not, the MCO’s would have to conjure up the ghost of Clarence Darrrow to convince a jury that turnaround times counted in WEEKS do not violate the relevant standard of care. Stir a little evidence of willfulness (i.e. internal memoranda confirming intentionality) into this negligent stock and you have a witch’s brew toxic enough to give even the most cynical corporate counsel dyspepsia. We hope that their adversaries on the personal injury side are paying close attention, and that the tally of preventable suicides, strokes, and adverse consequences can be kept to a minimum until the scales swing once again into some semblance of balance.