House Calls / Dr. Michael Schwartz

Insurance companies are placing increasingly more restrictions on patient care. Whether requiring a pre-certification to visit a specialist or a pre-authorization for a specific medication, physician offices are inundated daily with additional work to ensure that patients are receiving appropriate care. These restrictions result in patient confusion and anxiety, and physicians are becoming seriously concerned that insurers are making medical decisions based merely on cost and not the patient's best interests.

Despite the medical management decisions made in the examination room, the patient-physician relationship is continuously strained by arbitrary limitations placed on them. Even more disturbing is that these decisions are often made by non-medical professionals making decisions based on pre-determined guidelines. Unfortunately, many tests and medications are denied coverage despite the best efforts and appeals by the ordering physician.

The following are some examples of controversial insurance "protocols" I have encountered in my practice:

It is common for insurance companies to request that physicians change one class of blood pressure medicine to another. Specifically, I have received frequent requests to change an angiotension receptor blocker (ARB) blood pressure drug to an angiotension converting enzyme (ACE) blood pressure drug. Although similar, they each have different side effects. For example, ACE inhibitors can cause a cough. When this occurs, it is necessary to change an ACE to an ARB. Insurers often fail to recognize the medical reason for the change and will send a letter to the patient and prescribing physician directing a change back to the ACE. In doing this, the insurance company is actually making a medical decision to change the patient's treatment, which may result in an adverse reaction for the patient.

Requests for medication changes are also very common with antidepressants. Recently, I had a patient who took the medication Fluoxetine. For this patient, it did not have the desired effects and I changed the medication to Duloxetine. At the follow-up appointment, the patient reported that she was feeling better than she had in years. However, when she tried to refill the medication she was informed by the pharmacy that the insurance company directed that the Duloxetine be replaced by a different medication. She was disturbed and confused since I did not change her prescription and because she had finally found a medication that was working well for her condition. Despite this fact, she was being told by her insurance company that this other medication was the "preferred" medication and she would have to switch drugs in order for coverage. The entire situation resulted in increasing her anxiety.

Another regular insurance restriction is with anti-acid medications. For example, a patient had been on the medication Esomeprazole for many years. He had tried many similar medications in the past without improvement in his symptoms. However, because there was no documentation of all the other medications he had tried over the years, the insurance company rejected the medication and forced the patient to go back and retry the over the counter alternatives before they would approve coverage.

The patient suffered severe heartburn symptoms for two weeks while he tried the alternative medications required by his insurance company. The medication was eventually approved, but only after the patient suffered unnecessary discomfort.

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An even more confusing scenario is when a patient's medication, which had been previously changed (as directed by the insurance company's formulary requirements) is changed back to the original medication because the insurance company once again changed their formulary back to the original medication. This confuses the patient and shows that the formulary is not about good care, but is about cost.

Last year, a patient came in with back pain. The pain radiated into the left foot indicating a probable diagnosis of sciatica. The patient's pain was so severe that he was unable to work. An MRI of the lower spine was ordered, but coverage to do the test was rejected by his insurance provider. The patient was required to first try anti-inflammatory medication and physical therapy. After several weeks of severe pain without improvement from the physical therapy and anti-inflammatory medication, an MRI was approved. It showed a severe herniated disc requiring surgery. The patient suffered unnecessary pain for several additional weeks due to the restrictions of his provider.

While not all insurance companies require medication changes or restrictions in access to medical tests, it is becoming more common as the insurance industry undergoes changes forcing it to be more cost-conscious.

For physicians, the arbitrary regulations implemented by insurance companies are a barrier to administering sound care. Patients pay a high price for their coverage and should be alarmed that decisions are made by their insurers based on cost rather than the patient's best interest.

Patients who are not satisfied with these denials have the right to appeal; if still not satisfied, patients can contact their state's insurance commissioner.

When medical decisions between you and your doctor are overruled by the administrative regulations of insurance companies, this is equivalent to practicing medicine without a license.

Dr. Michael Schwartz is board certified in internal medicine with a private practice in Darien. For comments or questions, please visit his website at