As a certified nurse practitioner working in primary care, I’ve spent the last eight years treating and interacting with patients every single day. In that time, not enough has been done to address one of the biggest challenges facing Michigan patients: a lack of adequate access to the medicine they need.
My official clinical diagnosis is simple — the process for prescribing life-saving medications in this country is a disaster, and the lion’s share of the blame lies at the feet of health insurance companies.
Because of red tape and regulations — e.g., requirements that physicians and nurse practitioners obtain prior authorization from an insurer before prescribing, and restrictive formularies that push patients towards older and less effective medicines — and because of recent insurance plan changes that no longer apply co-pay coupons to a patient’s out-of-pocket cap, many of my patients are struggling to get the medicine they need. The need for prior authorizations also negatively affects a patient’s ability to obtain procedures/interventions that may avoid a lifetime of medications in the first place.
At our small practice in Detroit, my fellow providers and I treat dozens of patients every day. We examine them, assess them, and we get to know them. The good news for many patients is that their health challenges are treatable. Sometimes, it’s as simple as more exercise or a change in diet. Very often though, prescription medication is an essential component of their treatment plan.
Medical science advances by leaps and bounds each year, making it possible to better treat addiction, sicknesses, and disease. Unfortunately, simply knowing a patient needs a specific medicine is no longer a guarantee that the patient will have access to that essential treatment. One of the biggest barriers standing between patients and the prescriptions they need are health insurance practices, particularly the myriad of confusing prior authorization requirements that are designed to put the insurance company’s bottom line above the health and safety of patients.
Here’s how the crisis unfolds: First, a patient comes to the office for a visit. We do an exam, we run the tests, we make a diagnosis. Next, we work with the patient to identify a treatment plan, which sometimes includes a prescription medication. Finally,the patient – who has insurance – simply goes to the pharmacy and picks up the prescribed medicine … right?
Wrong! It should work that way, but it doesn’t. Instead, the patient’s health insurance company steps in and determines whether they’ll cover the patient’s medicine, based on their profit margin rather than how badly the treatment is needed. Sometimes, the insurer requires a long and difficult prior authorization process that delays a patient’s access to the medicine he/she desperately needs. Sometimes, the insurer denies the patient access to the medicine altogether and requires him/her to use a less effective (if it’s effective at all) alternative medicine that improves the insurer’s bottom line. This leaves the patient with a choice: use the less effective medicine and suffer the health consequences, or pay more out-of-pocket for the medicine that works best while her insurer continues to pocket her monthly premium.
The reality is that newer medications are more expensive because they are costly to develop and the pharmaceutical company has to recapture income committed to that new development. It is a necessary evil to provide for medical advances. However, because of the price tag, insurance companies will not approve new medications and delay medical progress and patient treatment for their bottom line. This is unethical from a provider perspective. The first line of the Hippocratic Oath is “Do no harm.” How much harm are we doing by allowing insurance companies to deny our patients the care they need? Delaying care until the generic equivalent is available can delay a patient comfort, health, and functionality.
For most patients, especially the low income patients we treat at our office, that’s no choice at all. When insurers deny patients access to the medicine they need, and their health suffers, it creates an expensive medical cycle that the patient becomes trapped in. If they can’t get the proper medications to treat the condition, the condition advances, comorbidities occur, functional status declines, and thus the wheel turns with no chance for the patient to get out of it.
To make matters worse, many insurers have announced they’re no longer going to apply co-pay coupons from pharmaceutical manufacturers to a patient’s annual copay. In a new system (that screams for attention from our incoming Attorney General), insurers will keep collecting the coupons from manufacturers, but then they’ll double-dip and charge patients again. In a system that is already breaking, practices like this will put a wedge in the health care system, further damaging the medical field, the patients, and the nation. No wonder so many patients have a hard time adhering to their treatment plans or sticking with the medications that work.
This is a crisis our leaders should take a long, hard look at when they arrive at their desks this season.
Jordana Latozas is an Acute Care nurse practitioner in Michigan. Her specialties have been in Chronic and Acute Pain. She currently works at a primary care and Addiction Medicine clinic in White Lake, Michigan, and as a Hospice and Palliative Care NP. She holds certifications in Pain Management, Critical Care Nursing, and Hospice and Palliative Care.
A version of this article was previously published in The Detroit News as a Letter to the Editor in December 2018.