Opinion: Insurance Companies Use Medically and Fiscally Irresponsible Formularies

Image Credit: nito/shutterstock.com

Receipt of an unsolicited communication that a sweepstakes award has been won may con some people (especially, but not limited to, those underprivileged or undereducated as to legalities), but can’t fool all of the people all of the time. The names of the organizations and products involved are often marketing tool inventions, which imply special personal benefit, but neither actually warrantee nor subsequently provide delivery of the product that their advertisements suggest.

Offerings with the suffix “for you” or “for life,” perhaps, should be suspect, especially when incorporated into the name of an insurance company’s medical insurance product. Less obvious are insurance products that call themselves by the same acronym as that utilized by a university in the region. One might perceive this as an attempt to suggest a relationship with that university and, thus, achieve additional insurance company credibility. When quality issues are subsequently raised (e.g., insurance company patient care directions), that university appears to quickly distance itself.

Practicing Medicine without a License?

Examination of insurance company utilization of formularies provides clear guidance as to whom they are committed. Off-label prescriptions are often denied reimbursement, unless the insurance company demands such use, the latter often in lieu of an alternative medication that is FDA approved for that indication. Insurance companies claim their formularies have been designed by physicians and pharmacists, but refuse to identify those individuals and provide no documentation of such derivation or even scrutiny.

When the fallacies of their formularies and the significant patient hazard and actual damage they impose are documented, insurance companies (at least in this area [Pennsylvania]) refuse to even acknowledge the querying communication. They refuse to make their medical director available to discuss the issue (be educated) and refuse to identify who actually constructed their formulary. They remain mute, even when presented with evidence-based rebuttal of their formulary direction mandates and expressed concern regarding how their promotion of illogical and unsafe medications appears to constitute insurance company practice of medicine without a license.

Even if the insurance company considers its formulary a way to reduce its payouts, this approach is still fiscally irresponsible. It demands utilization of medications or modalities that are ineffective, create additional morbidity or are actually inaccessible to the patient.

The associated mortality related to some of the formulary directions perhaps could be considered cost savings, if one were to consider the insurance company decisions as that diabolical. Some formulary demands might superficially appear reasonable, until one actually examines them. Typical is a promotion of medications with the side effect of producing drowsiness. This is a dangerous method and actually does not induce restorative sleep.^1,2 It just reduces the patient’s cognitive abilities and increases their risk of falls and other injuries.

Appeals

Some insurance companies have an “appeals process” called “peer to peer.” Although one rarely does have the opportunity to discuss the issues with an actual peer (a physician in the same subspecialty), that “peer” typically indicates they don’t have the authority to deviate from the formulary and they and the insurance company refuse to provide access to those with the authority. Most communications involve the “peer” stating the party line, perhaps listening to an evidence-based rebuttal of the insurance company’s formulary directions, but then simply denying the request—saying it deviates from the required formulary. One intriguing example of this was when an insurance company “peer” recommended use of an antidepressant to treat arthritis—in a patient with ulcers—for whom the actual request was for celecoxib.