I’m a psychiatrist who works with people with severe substance abuse problems and mental illnesses. Over the years, I’ve tried to make peace with insurance companies that have become prescriptive in what they will and won’t cover.
Recently, as one of the social workers spent the bulk of her day negotiating with a managed-care company that insisted we prescribe a 90-day supply of medication to an unstable patient, I had a moment of clarity. Of course, I thought, this makes perfect sense. Give the patient a lethal dose and have it be the doctor’s fault. Brilliant!
By way of comparison, when I’m working with a new and unstable person, a week or two of medication is the most I will give. This will be increased as they are doing better, with a month — at times with a refill or two — being the most I will prescribe at a time.
IT WORKS UNTIL IT DOESN’T
This is the fourth insurance company that my staff and I have come up against on this 90-day rule. Clearly there’s a cost saving to the insurance company to have the patient’s medications filled via a cut-rate mail order pharmacy. I don’t have an issue with that; I think for most people, with most medications, that makes sense. Although I do wonder what happens if the dose needs to be changed or someone has a bad reaction . . . that’s a lot of pills to waste.
My gripe is that for people who daily struggle with impulsive behaviors, substance abuse and suicidal thoughts and actions, a 90-day supply is like keeping a loaded gun in the medicine cabinet.
For those not used to the world of high-risk psychiatry, you might think, “If people want to kill themselves, they’ll find a way.” There is truth in that statement, and it is also true that instant access to lethal means plays a big role in completed suicides. That’s why the bulk of suicides in this country occur with firearms.
In years past, the No. 1 drug in lethal overdoses was a no-longer-popular antidepressant — amitriptyline (Elavil). So psychiatrists are well-versed in the reality that the medications we use to help can also be the method by which some patients end their lives. A 90-day supply of anything for people with unstable psychiatric and substance abuse problems is dangerous and a bad idea.
If I were to suddenly become a managed-care executive, however, I could see how this 90-day rule makes tremendous sense. I think about the people I work with — many would be considered high utilizers. These are folks who require expensive, at times prolonged, courses of treatment. They often have multiple psychiatric diagnoses compounded by severe addictions to drugs and/or alcohol. Relapses and hospitalizations are par for the course. To be blunt — they are expensive.
Providing their care cuts into insurance company profit margins, especially now when lifetime limits on mental health and substance abuse disorders are being phased out. What’s a savvy insurance executive to do? I know, give them 90-day supplies of medication and the ones who are the most ill will take their lives. Problem solved and for pennies on the dollar.
I’d like to think that I’m a stretching the point. But having spent hours on the phone with insurance companies unwilling to budge on this rule, I know that most doctors and advanced practice registered nurses for whom this is an issue, write that 90-day prescription. I can’t blame them.
The alternatives are that the patients don’t get their medication or have to pay for a smaller and safer amount out of their own pockets. Sometimes creative solutions can be found, such as having a family member hold the medication, or having a visiting nurse monitor it, but those options aren’t always possible, appropriate or acceptable to the patient.
End of the day, this 90-day thing is just one in a long list of how and why the current health insurance scenario is not in the patient’s best interest. The driving force is profitability. Where that’s the case, it makes sense that rules should be structured to winnow out individuals whose conditions drive up cost and drive down profit. If people die along the way because of this, that’s just part of the cost of doing business.
Charles Atkins is a psychiatrist and author, and an attending psychiatrist at Waterbury (Conn.) Hospital and an adjunct faculty member in psychiatry at Yale School of Medicine.