Games insurers play

Imagine that you are a 70-year-old cancer patient who lives on a fixed income. You are undergoing chemotherapy and dealing with the awful side effects of chemotherapy. Now imagine that you also have debilitating arthritis that is so extensive, you can’t stand for more than a few minutes or enjoy a nice outing with your grandchildren.

Because of the effects of the chemo, most NSAIDs and steroids are contraindicated. Your physician works with a local compounding pharmacist to come up with a topical preparation to manage your arthritis. You try a bit of it and find that while the multi-component compound does not eliminate all your pain, you can stand up and cook a Sunday meal. Best of all, you are able to have some quality time with the grandkids.

But there’s a fly in the ointment: Your insurance carriers, both Medicare Part D and your private provider, tell you that they just do not cover compounded medications - any compound - for any reason.

Why? Because they do not want to.

Shame on them! And shame on organized pharmacy, medicine, and individual practitioners for not forthrightly addressing this problem and advocating for patient coverage.

Tactics galore

Insurance companies constantly come up with a plethora of reasons, including the non-reason above, for not covering compounded medications. Many just do not make sense. Many fly in the face of reason. Some appear to be strategies designed to put administrative hurdles in the way of patient care. 

Ironically, in most cases the components of these compounds would be fully covered if the products were taken orally. If given orally and separately, they usually would cost the system more than if they were delivered in a compound. 

Even when components may not be clinically appropriate, this does not seem to figure into initial coverage decisions. In some cases, reductions in medication concentration would make a difference. But here again, too many insurers just say “No.”

In the latest twist, compounds that were covered last month are now being denied coverage, with no rhyme or reason to the reimbursement denials.

Rules? What rules?

As if all this were some type of computerized fantasy game, the rules are often hidden. If you figure them out, the compound is covered; if you don’t, it isn’t. Unfortunately, for the patients we are talking about, this is not a game; it is poor patient care.

It also frustrates prescribers, compounders, and patients to the point where they just don’t want to bother pursuing this course of treatment, and instead acquiesce in the use of commercial products. Hmmm. Perhaps that is the point of all this obfuscation.

What to do?

So, what to do?  We must aggressively engage in the discussion and engage our patients in it. Wouldn’t it be a powerful coalition if pharmacy, medicine, and patient groups came together (including perhaps even AARP, whose mission is to help seniors live healthier lives) and formed a coalition to address this issue? 

We also must support broad-based advocacy programs such as “Protect My Compounds,” which PCCA (Professional Compounding Centers of America) is championing. All pharmacists and prescribers must support programs that bolster the rights of patients to the same reasonable reimbursement - and hence access to compounded medications - as they have for commercially available medications.

To be sure, there are prescribing, dispensing, and billing abuses attributable to practitioners, and these too must be vigorously addressed. These abuses hurt the image of the professions, encourage reimbursers to rationalize “clamping down” on payments, and ultimately hurt patient access to needed medications.  But system abuses are found in every sector of healthcare, and these are managed, not designed to shut down reimbursed access - or to look like some sort of mystifying computer game.

Salvatore J. Giorgianni Jr., is a consultant pharmacist and president of Griffon Consulting Group Inc., an advisory board member for Pharmacist Partners LLC, and Drug Topics, and chair, American Public Health Association Men’s Health Caucus.