I won. It felt like losing.


I suppose I got mad for a spell

On the issue of testosterone gel

For more lab the rep asked it,

And I blew a gasket

I won, I’m not proud to tell. 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska.

Technically, I don’t work the afternoon after night call, but I rounded on 17, discharge 4, had a leisurely lunch and went to the office.

The tide of mail and email doesn’t stop when you go on vacation.  I sat at my desk behind a closed door, and steadily worked my way down the stack of paper.

Near the bottom I came across a note from an insurance company dated 8/30, demanding information within 5 working days, or my patient would be past any appeal of a denial of coverage for testosterone gel.

(I have a lot of patients with testosterone deficiency.  Insurance companies notoriously drag their feet about paying for high-priced meds.  I have revealed no unique information about anyone.)

This particular insurance denial of coverage for this particular medication goes back 10 months.  I appealed at the time.  They thought for 90 days and wanted me to get more lab work, which I suppose seemed reasonable in a far-fetched way.  They thought about it for another 60 days and sent a letter telling me I had to have appealed on a different form before the deadline which had now passed.  I called and spoke with a representative who told me to get more lab, which I did.  With new numbers in hand I called again and got put on hold for a quarter-hour.  I fired off a well-worded, articulate, calm letter to the company, which never got acknowledged.  I called again a few months later and talked to a different rep, who said, another imaginary deadline having passed, that the patient would have to make his own appeal.  I sent the patient a letter recapping the events, telling him the company’s dealings lacked good faith, but urging him to call the company; I sent the company a copy.  And there the matter stood when I went off to Alaska.

I struggled to keep my voice calm when I spoke with the rep.  Such a deadline could never be considered reasonable, I asserted, I had been gone and it was only under the thinnest of coincidences that I happened upon the letter in September at all.

She told me she’d gotten a call from my office and that on the basis of only one lab result the medication could not be approved.

I blew a gasket.

“I’m telling the patient to get a lawyer,” I said.  “I suggest you talk to corporate counsel today to figure out how he’s going to defend this thing because I have copies of letters that I’ve been sending and you’ve been shredding and it’s going to look very bad in court.”  I didn’t raise my voice.

Silence reigned at the other end.  I ended the call courteously.

I had my nurse give the patient the info.  For the first time in thirty years, I suggested the patient retain legal counsel.  And asked him to come in for one more round of lab tests.

The rep called me back a few minutes later to tell me that she’d spoken with the committee and the denial had been rescinded.

I had my nurse phone the patient.

I felt good about getting the patient the medication he rightfully deserved, bad about blowing a gasket, and worse that blowing a gasket had worked.

It’s not a technique I want to use frequently.

The patient decided to drop his insurance, feeling, rightfully, that the cost was certain but the benefit doubtful.

 

 

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2 Responses to “I won. It felt like losing.”

  1. Charlie Miles Says:

    Somewhat similar circumstances for the same medication for me.

    Originally approved for gel for a few months, then suddenly, only patches or injections are covered…and this after a lot of confusion and run around at that.

    Patches to not stick well, one fell off in Walmart one day! I also have to use medical tape to cover the patch…AND my skin breaks out where the patch is applied…I change locations daily.

    Further, I don’t seem to get quite the same “oomph” as I did with the gel, but the next lab results will determine if that’s just my imagination or not.

    My endocrinologist told me he had some female patients with higher levels than me…so it is a help to have it in whatever form.

    One wonders when the added layers of bureaucracy of Obamacare kick in what will happen. Surely it will be better than this?? HA!

    While I don’t often comment, I do want you to know I really enjoy your writing and always look forward to your next post!

    • walkaboutdoc Says:

      Every time the government moves, bureaucracy increases; it will increase with the ACA.

      The gel really is superior, the patch is second best, and shots are third. Pills are almost out of the question. I haven’t known anyone who used a patch for more than three years before they had to quit because of adhesive intolerance. If you show your doc the marks, you can probably get back on the gel.

      That being said, the only testosterone replacement available in all of New Zealand is the injection, and the infrastructure has been set up to handle it. It does OK, and probably the guys like it for the three or four days of extra oomph it gives them before they get to a normal level for a week, and they don’t really mind the low level for the last 3 or 4 days.

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