Insurance Companies Overrule Doctors on Prescriptions

The practice of medicine is, to a great extent, controlled by private insurance companies. It is not enough that your doctor orders a test, like an MRI. The insurance company must pre-approve the test and the provider of the test. Take the test without pre-approval: insurance company won’t pay. Go to a different testing center than the one pre-authorized: insurance company won’t pay. Need non-emergency surgery: insurance company won’t pay unless IT determines that the surgery is medically necessary. These are not government programs. In fact, it’s a lot easier to have a procedure approved if you’re on Medicare rather than private health insurance.

Similar problems arise when an individual requires specialized medication. For example, people who have received organ transplants must take anti-rejection drugs every day of their lives. Some anti-rejection drugs are brand named drugs which were patented. Those drugs can be extraordinarily expensive. There may be generics of some of those drugs, but many doctors do not want to permit generics, and with good reason. Generics are similar, but not identical to the name brand they are intended to replace. It is the differences that concern many physicians.

The big problems is that generics can vary from manufacturer to manufacturer. The people who provide the drugs – – pharmacies and insurance companies that directly send drugs to patients – – are naturally attempting to maximize their profits. As a result, the manufacturer of the generic drugs you take can and do change from month to month. For many people that can cause enormous problems.

First, many doctors just don’t trust some generics. A good example is Synthroid which individuals with thyroid problems take. There are many endocrinologists, the specialists who treat thyroid problems, who believe that the generic version of Synthroid is just not as good as the “original.” Since many insurance companies will not pay for the “brand name”, in order to get the “brand name” the patient has to go out of pocket for the entire price of the drug. This is an expense that many people can’t afford, so they are forced to take the generic despite their doctor’s orders to the contrary.

Transplant recipients have particular issues with generics. The anti-rejection drugs these patients must take every day of their lives have to be closely monitored in order to make sure that the correct dosage is achieved. Generics of those anti-rejection drugs do not act in exactly the same way as the brand names, and each generic is a little different from all the other generics. Every time a patient is given a new formula of the same drug, extensive testing is required to insure that the right dosage is achieved. And, if the generic changes every month, which it often does because the insurance companies are looking for the cheapest product on the market, the patient is forever required to test and re-test to make sure they are getting the right dosage.

While drugs like Synthroid are relatively inexpensive, brand name anti-rejection drugs can cost thousands of dollars each month, and even the generics cost hundreds of dollars a month. For those people lucky enough to get life-saving transplants, this means that most transplant patients are left with no alternative but to take the generics contrary to their physician’s orders.