By Mark David Blum, Esq.
Indeed it has come down to my being an irrelevant but interesting statistic.
About a year and a half ago, I was diagnosed with a serious ailment requiring some intense pharmacological therapy. One of the meds, we will call Drug X was recommended to me to be taken in dosage Y one time per day. For about a year this drug was doing its thing and I started to heal. A few months ago, the drug started to lose its efficacy and so my doctor increased the dosage to Y twice a day. The impact was immediate and I haven’t felt that good in years.
For about six to seven weeks I was taking the increased dosage until one day my pharmacist says “no more”. Apparently the insurance carrier (which I wont name but which rhymes Schmidelis) had determined to not authorize distribution of the second daily dose. After cleaning out my doctor’s offices of all his free samples and convincing the pharmacy to keep honoring the prescription until the issue with the insurance company was settled, it finally came down to “no means no”.
My doctor and I both did our homework and here is what we learned. Eli Lilly, the drug’s manufacturer did a series of studies on the drug and found in three of four studies that its potential benefit significantly diminishes after the dosage I was already receiving. A fourth study revealed that in a small control group, there was indeed noticed and marked benefit at higher doses. But, after FDA trials and protocols were set, the FDA determined that there was no real benefit at the higher doses and thus did not sanction the drug’s use therefor. Because the FDA did not sanction the drug for use at higher doses, the insurance carrier has denied any coverage. At several hundred dollars per month for the increased dosage, I too am not funding the increase. Consequently, I am back now at the lower dosage and am learning to find my way through the pain and suffering and to be thankful for what help I can get.
Herein lies the fundamental argument I have about insurance companies. Some faceless nameless entity intervened in a relationship between a doctor and patient and determined for the doctor and patient what is the best course for treatment. Having never met the insurance company, having never spoken to a single physician working for the carrier, and never having had the opportunity to even discuss the issue, this non medical agency began practicing medicine without a license by telling me that I am not “entitled” to a higher dosage even if it helps.
Yes, there is an internal appeals process to which the doctor and I both took advantage of. Additionally, being an attorney, I used my skills to work my way up the food chain at both the insurance company and at Eli Lilly. Both confirmed that while there is anecdotal data showing benefit for some at increased dosages, there was not enough data to convince the FDA to recommend use of higher doses when needed.
To all the secretaries, clerks, Vice Presidents of This That and the Other, and to every other person at both corporations; I thank them for their patience. The word “no” is not a word I generally accept without a fight and I did all I can to investigate and resolve the issue. Nope, happy as they are to take premiums from me and taxpayers (Schmidelis does a lot business with Onondaga County), absent an FDA recommendation, I was told to suffer and basically go to hell. Eli Lilly’s Vice President of SuchnSuch told me he felt my pain but in the end, there just was not enough data to bother dealing with the FDA.
My doctor, God Bless his Soul, might make a good lawyer some day. He sure knows how to turn on the pressure and anger when he is being given the runaround by an insurance company. Like me, he too tried to get Schmidelis big shots on the phone for an explanation and like they told me, the insurance company told him to go to hell. I was not going to get the needed treatment. He could not explain to me how the insurance carrier could be practicing medicine without a license and involving themselves in the patient doctor relationship. Schmidelis is supposed to take the premiums and pay out benefits when billed. I doubt they have the legal right and authority to override a doctor’s determination. If the insurance company has the legal authority to override a doctor’s determination of treatment and can do so without a license to practice medicine or having met the patient, then they should be able to be sued for malpractice. You cannot have it both ways. Onondaga County should also reconsider to which companies it hands out its precious millions for its citizens. (If they can tamper with my contractual relations, then surely I can tamper with theirs).
Eli Lilly is also to be commended. I had done my homework so was able to talk shop with Eli Lilly VIPs. There was no real help they could give me but they did confirm that there is no real hard data done in large group studies establishing a strong enough efficacy beyond a certain dosage to warrant an FDA recommendation. We talked for a few hours about the drug and policy and the particular impact the drug had upon my life. He gave me the “I feel your pain” response and thanked me for my time. In the end, however, there was no help forthcoming from Eli Lilly.
In the end my doctor tells me there is nothing more he can do because he is, in his own words, “just a lowly doctor”. I responded by saying, “imagine that --- and I am but an anecdote.” Indeed I am. My experience with the drug and its benefits at above the recommended dosage, however positive, is nothing but anecdotal data to the insurance company and the manufacturer. It matters not that I experienced substantial relief and an end to pain and suffering when taking the increased dosage. That data was just tossed into the anecdote file at Eli Lilly along with my peace of mind.
Highly paid lawyers and marketing firms have convinced the media that the cost of medicine is skyrocketing because of lawyers, because of duplication, because of greed by hospitals and doctors, because of defensive medicine, and because we allegedly have the best health care system in the world making the cost something we do not negotiate. After all, whom among us is willing to go short on medical care?
The facts establish that none of the marketing points made by the big pharmaceutical and big insurance industry are true. Lawyers and lawsuits are not the cause of high premiums, they are just who gets the blame.
If you want to know why hospitals, pharmaceutical companies, and insurance companies get sued, take a look at my situation. Because of my status as an anecdote, I have to get through the day in great pain. Imagine if one day that pain gets the best of me and I snap. The damage to me possibly others or property could be tremendous. In my heart, I know who will pay; or at least who will get sued.
This situation exposes the two fundamental flaws in our nation’s health care system. First, doctors are restrained and trained to work in a field where statistical correlation is the fundamental basis for their science. “If I do this, I get that result 90% of the time” is how most of medicine is based. It is all Voodoo science; if you ask me. The second flaw is we refuse to allow our doctors to treat us as individuals and instead rely on insurance carriers who make their determinations based on groups or class. “This group can get that benefit but only if ….” Removing insurance from the equation will remove a very costly middle man. The role played by insurance companies; whipping up fear and panic is the #1 direct, actual, and proximate cause of skyrocketing and out of control medical service costs. Insurance companies are directly responsible for a markup which triples again threefold the cost of services rendered. Insurance companies fix the market prices. Insurance decides the services that cannot be rendered and which ones must be delivered. Cutting out the middle man will force the market prices to adjust, alternatives to financing will be reached such as doctors and hospitals carrying the paper (like the rest of the world), and a more sane and rational balance will be found.
In the end, we need to repeal the Harrison Act such that my doctor, like my plumber and electrician, becomes a hired contractor for me, makes his or her recommendation about treatment and pharmacology, and then I go down to sit with my pharmacist and together the three of us determine a regimen of drugs and whatever other treatment. Final decision making authority should be mine and mine alone. No insurance company, no paternalistic medical professional should have the ability to override what is deemed necessary to eradicate pain and heal ailments.
At a minimum; since I know Onondaga County funds this same insurance carrier through its Child Health Plus and Family Heath Plus programs. Perhaps it is time for the County to defend its citizens. Cut off any use and payments to this carrier until such a time as it recognizes the value of ending pain and suffering. I don’t need a life where I learn to function with pain. The technology is there now to enable me to function pain free but it is being deliberately withheld. No more taxpayer funds for an insurance carrier that gives nothing but a finger in the eye to its policy holders after cashing their checks.
As for me, the battle continues. I can assure you that anecdote or not, I will not go quietly into that good night.
