What Happens When Insurance Companies Dictate Psoriatic Care?

Medical care is quite a state of transit. The way things worked in the past, even as little as 10 years ago, is vastly different than how things work today. Everything related to medical care should have the best interests of the patients at its core. But sadly, in my experience, that isn’t always the case.

How insurance companies call the shots

These days, insurance companies, not doctors, call the shots. Too often, they decide what the “medically appropriate” course of action is. They decide which medications are “covered” and which are not. Not only that, but insurance companies can also make certain medications and treatments cost-prohibitive for many patients.

Staying within the insurance guidelines

Dosing schedules are often not dictated by your doctor either. Because insurance companies are the gateway to making expensive medications “affordable,” they also have a say, not only in what medications are allowed but also the strength and frequency of the doses.

Yes, these parameters are put in place by insurance companies, overseen by doctors, and in theory, were created to make sure doctors and other health care practitioners stay within the guidelines of safety. However, doing this takes practical patient care out of the hands of the same doctors that are directly involved with individual outcomes of patient care.

Sticking to a medical care schedule

For example, one of the medications that I am on has an every 4 weeks dosing schedule. Meaning that I receive the medicine, in shot form, once every 4 weeks and not a day sooner. Yet, the medication consistently wears off just over a full week before my next scheduled dose.

There I sit, counting the hours until I am “allowed” to get my medication and feel better again, simply because the dosing schedule for my medication indicates every 4 weeks. Insurance won’t cover it if I am even a single day before the 4-week marker.

Determining medical dosing

My doctor is the one who should have discretion over exactly what my dosing schedule should be. If he/she notices that a patient has found (by some miracle) a medication that actually works, yet wears off a bit too soon, my doctor should have the final say over the dosing schedule, not my insurance company. Going “off label” isn’t an option for most people.

What makes this even harder is that I know how much money my health insurance company “saves” me each year with each medication, appointment, and test. I have about a thousand statements piling up and enough EOB’s to wallpaper my whole house.

I know my insurance pays a huge chunk of my increasing medical expenses. But does that give them the right to dictate which medications, procedures, and tests are right for me? I say nope.

Who knows best about psoriatic arthritis?

If my trusted medical doctor decides that a test, medication, or procedure is necessary, shouldn’t their judgment trump that of an insurance company? Insurance companies should not have the right to say they will only cover certain medications under specific scenarios.

For example, many insurance companies will now allow you to try a biologic until you’ve tried such medications as methotrexate or sulfasalazine and failed on those. Even if your doctor believes that a biologic would be a better treatment for your psoriatic arthritis.

When the patients pay the price

Whether you agree that everyone should or should not try methotrexate first isn’t really the point. What matters is, that decision should lie in the hands of the patient and their doctor, not with insurance companies, simply because they hold the purse strings.

When insurance companies are allowed to dictate medical care guidelines, too often, it’s the patients who have to pay the price.