Susan Paynter, columnist at the Seattle Post-Intelligencer, wrote a great column on Monday about the problem with insurance companies refusing to pay for certain antidepressant medications prescribed to treat postpartum mood disorders. To read the entire column, click here. Paynter uses the example of a new mother named Jessica Lane whose insurance company Group Health required her to try several other drugs before agreeing to pay for the one she was prescribed and knew would work after using samples from her psychiatrist. As you know, it takes a couple of weeks to find out if a medication works, so on the outside chance none of these other drugs work, a patient would have to continue to suffer for at least two more months if not longer just to save the insurance company money, which is absolutely awful.
Here is an excerpt:
"Meanwhile, what happens to my family?" Lane asked. "I could spend the next year of my life experimenting with different side effects just so they don’t have to pay for the one (drug) that already works for me. That’s not only absurd, it’s cruel."
Group Health’s director of clinical pharmacy services is Jim Carlson, who reasons that it’s not a matter of Group Health second-guessing Lane’s physician.
"I wouldn’t call it second-guessing because the patient can still get the medication."
That is, if the patient pays for it herself.
"In general, most of the drugs used for depression have been shown to be equally effective and tolerated equally well in large populations of patients," he said.
That leaves the only thing left to define, and that is the cost effectiveness of care. It makes sense, Carlson said, to sequence the use of medications in order of cost.
In some rare cases, Carlson said, drug A may not work or be tolerated. Say drug F is on the high end of the cost spectrum. "We don’t try to micromanage a physician’s prescriptions or use of anti-depressants," he said. "But, if there are several (drugs) that are comparable in cost, then let’s try the other three or four first."
A patient doesn’t have to go from A to B to C. She can try C, then D and then B.
But can’t that take an awful lot of potentially troubling time?
"Indeed," Carlson said. "But there is no real evidence to support that leap (from drug A to the more expensive drug F) based on literature. No way to predict it will be best."
How about the fact that it already IS working, Lane asks?
I don’t know what Group Health’s research shows, but I know that I had to try many different drugs and they all had very different effects on me — I’ve taken Celexa, Serzone, Effexor, Luvox and Cymbalta. I certainly hope that what I was being prescribed by my psychiatrist wasn’t being dictated by some cost-effectiveness schedule of my insurance company. I didn’t to deserve to continue to suffer, nor did my child, simply to save money. Paynter sums this up so well that I’ll leave the last word to her:
Still, we need fewer hoops and more help for moms who may lack the coverage and the navigational skills that Lane does have. "It’s as if the insurance company is telling the woman and her doctor that they know best," she said.
"This is the very attitude that leads women to feel weak and ridiculous for even considering they might need help. When I got off the phone (after calling the insurer for an explanation), I just sat on the floor and cried. It seems like it’s cheaper for them if I’m nuts or if harm comes to my children. What about women who don’t have the resources and the wherewithal to fight this?"
Headlines or not, what happens to them, and to their kids, should matter to us all.
