Multiple Sclerosis (MS) is a progressive, disabling, neurological disease which is probably one of the most difficult diagnosis to confirm. Once confirmed, it is an extremely challenging condition to treat effectively.
One can classify treatment for MS into 3 broad categories – Disease Modifying Therapies, Symptom Management, and Relapse Management.
Disease modifying therapies (commonly referred to as DMT) are medications which alter the immune system to prevent MS disease progression. Prior to 1993, we had zero MS DMT meds. Currently, we have 8 such meds (3 types of Interferons, Copaxone, Tysabri, Gilenya, Tecfidera, and Aubagio). Each of these meds are effective, and all have different mechanism of action. Meaning, they all work differently. You cannot interchange these meds and expect the same result.
When choosing a medication for a patient, I carefully review the side effects, their past medical history profile, what type of MS they have, and what type of delivery modality (i.e. injection, pill, or infusion).
A few months ago, a patient of mine was started on Copaxone, which is a DMT given as an injection. She had disease progression with worsening symptoms while on Copaxone. After a long discussion, we decided to switch her to Aubagio. When the request was submitted to her insurance company for approval, they denied the prescription, telling us she had to have failed at least 2 DMT meds.
Basically, the insurance company is telling us that she has to take a medication which she may not tolerate or may not be ideal for her, and have her develop further disability before agreeing to pay for the recommended medication.
I feel this is bordering on criminal. This is similar to telling a cancer patient she must try a chemotherapy which may not be appropriate for her. If her cancer spreads, then they will pay for the proper treatment.
Over the last 30-40 years, the physicians and patients have been very passive to these ruthless decisions by insurance companies.
Unfortunately, we are at the mercy of the insurance companies. As a physician, my livelihood depends on insurance companies. As a patient, their healthcare depends on insurance companies.
The insurance companies fully understand the power grip they have on the US health care economy. Since they have the deep pockets and the political connections, they continue to control our healthcare, and in the end, they determine who remains functional, who may get disabled, who lives, and who dies.
Their decisions are very subtle, and when a patient calls to argue, they very easily and quickly blame the doctors.
This is an unfortunate situation, and will only get worse as the years roll on.
I will continue to try to provide quality care to my patients, hoping the insurance companies agree to pay for the tests, services, and treatments I recommend.