I saw Mrs. C. last week. She’s a long-standing patient in her 60s who has proactively approached her complicated health issues which include:

• Type 2 diabetes

• Coronary artery disease

• Congestive heart failure

• High blood pressure, and

• Elevated cholesterol

Mrs. C experienced a period of depression after her husband left her. During that time, she didn’t focus on her health. Since then, she’s been well disciplined about exercising, eating nutritious food, and getting her blood pressure and blood sugar under control.

To help regulate her blood sugar, we used medication. Through trial and error, we moved from a prescription that had a significant side effect to one that appropriately managed Mrs. C.’s condition.

Should Your Employer Health Plan Dictate Your Health?

Mrs. C’s employer recently started using a chronic disease management clinic to monitor the use of expensive prescriptions. However, the employer also changed their formulary, and the medication that she has positively responded to was no longer covered. Understandably, Mrs. C was distraught. The medication regimen that has been effective for her was going to be disrupted, and this could affect her ability to control her risk factors.

In addition, Mrs. C’s blood sugar has been creeping up. She admits that she hasn’t been eating well. It’s possible that even with her prescription, she would continue to have elevated blood sugars. It’s also possible that her diabetes has progressed to where she has become partially insulin dependent. In this case, we may have to use insulin to control her blood sugars. However, we would prefer not to for several reasons:

1. Insulin can cause weight gain and more than likely, Mrs. C has too much insulin in her system because of her insulin resistance. Given her stage of diabetes, once we place her on insulin, it’s unlikely we’ll ever be able to take her back off of it.

2. She probably would not only need a once-a-day insulin pen but also likely need mealtime insulin as well. The cost of insulin pens is significant. Monthly it can range 400-$600, and if you have two different types you’re using, then you could be looking at nearly $1,000 a month.

3. The effective medication she has been taking is nearly $300 a month. If she is forced to use insulin, we’ll be increasing her total medication costs, plus placing her on medication that may negatively impact her ability to continue to maintain her weight and follow the nutrition program that has worked for her.

We agreed that the best course of action was 1) keep her on her current medical regimen, and 2) resume a nutritious diet. If this approach is not useful, then we can reevaluate her regimen and make changes.  

Who Should Tell You What Medication Is Best For You?

Unfortunately, it appears that her employer-based health plan is going to be inflexible. Remember I mentioned a medication that caused a detrimental side effect? They would like her to switch to that same drug. When she explained that she had a side effect that required a treatment intervention, they asked for supporting medical documents.

It’s frustrating that the manager of the health plan doesn’t trust my patient and me enough to believe that this side effect occurred. In actuality, the way we managed her side effect saved her employer health plan a significant amount of money in the cost of visits.

When I suggested to Mrs. C. that based on complicating factors, perhaps the chronic disease management clinic should help manage her diabetes for her, she indicated they wanted me to handle it. This is a frustrating dilemma. We have a clinic trying to control access to medications on behalf of the provider that’s unwilling to manage the conditions of the patient. In fact, they are making it difficult to provide the patient with the best care possible by creating boundaries for me as her physician.

Health Care Should Be Team Effort

Sometimes, those managing the health care dollars, step into the way of those entrusted to provide the health care. I understand the need to scrutinize the use of expensive medications, but our first priority is the patient. It’s an all too common example of the difficulties your primary care physician faces when trying to provide you with the best possible care.

We all should insist on a more integrated and transparent system: one where the payers, meaning the individuals and businesses who pay all the cost, have more influence on their individual treatment plans.

I understand the importance of integrated healthcare. If you have questions about a more personalized approach to your well-being, contact me. You also can like me on Facebook.