Insurance Decisions Will Affect MS Outcomes

Insurance Decisions Can Affect Our MS Outcome

You Could Be Denied A Treatment You Need to Treat MS

ALERT EVERYONE, there is a growing problem that you need to be concerned about. Insurance Companies are growing in numbers with lists of approved medications that they will now pay for. I know, you are saying they have been doing this for years. What you may not be aware of, because it hasn’t affected you, are that these lists aren’t just generic drugs over named brand medications. These lists are now incorporating important medications for different health issues, including Multiple Sclerosis.

Yes this is correct; I said that your MS could be directly affected in the upcoming future by your private insurance telling you what they will pay for…not what your doctor said you need.  With the growing cost of our medications, the higher priced more effective drugs like Gilenya, Tecfidera, Aubagio, or even Lemtrada will probably not being included on these lists.  Right now the government run programs are doing this already and it looks like we all are going to be included in this practice. It will take a great deal of proper documentation by your physician to get these medications approved for payment by insurance. Many individuals have their fingers crossed that Lemtrada will be paid for because of the regulations set up by the FDA, that you must have failed two prior treatments in order just too even receive this. Of course the FDA doesn’t set the prices of our medications, the Pharmaceutical Companies do. Makes me wonder if insurance cut these newer medications off their list, will make the pharms to reduce their price?

Our doctors have been losing their ability to diagnose and treat us appropriately due to insurance putting out restrictions as what hoops you must jump through, or time frames we must all wait to be able to have certain tests paid for.  As this practice has been tolerated by us, the payee, the only ones screaming thus far have been the physicians. Then when we are delayed a diagnoses, and diseases or disorders have progressively gotten worse, we want to blame the doctor. Wake up people, most physicians are following the silent rules put out by insurance companies! Their hands have been tied as to what protocols must be followed to be able to run certain tests like CT Scans, MRI’s, and many other procedures including surgery.

In simple, say you need Gilenya because your present medication like Betaseron isn’t working like it should, but your Insurance Company will only pay for Copaxone as the second choice. None of the medications out there to treat MS are inexpensive….let me just set the record straight. So my next question is, if you need a different medication due to progression of your disease, will it all comes down to increased proper documentation by your physician, along with many phone calls to override the denial process? Every insurance company has on staff nurses called Case Managers and physicians to review records of things that have been denied for payment. They rely on all the information by the treating physician to change their decision or uphold denial for payment. This information must include all test results such as labs, MRI’s or other diagnostic tests, and objective and subjective data of your symptoms, prior treatments, and reasons why you need new or additional treatment. I worked as one of these Case Managers for an insurance company; they would change their mind and pay if proof was made available.  With the craziness though and all this paper work already required by our physician, will they be willing to put in this additional time and effort for ALL of us in the future? I see the physicians having to add on to their staff to be able to provide us with this help. This means the cost of every office visit will go up to cover this expense. This problem is a whole other can of worms that doesn’t apply to this story but you can bet this will affect us negatively as well.

I do want to add though that because your MS is progressing, you don’t need stronger medications that offer more severe side effects for it to improve your condition. There is a physician named Mark Freedman, whom is a well-known MS Researcher from Canada, spoke directly toward this topic. He indicated that most times when the medication a person is on is not working, simply changing to another DMD with fewer side effects will provide proper treatment. I found that interesting because I thought a stronger medication would be needed to slow progression which simply isn’t the case.

All in all, it is us that are going to suffer from this upcoming problem! We need to be alert to this problem and start coming up with solutions. Since Obama Care has passed, we pay more already for less coverage. You can count on this fact; good healthcare is going to be less accessible along with much needed treatments for every one of us. The only way I see this changing are for regulations be set in place for insurance companies preventing these types of decisions being made. This means calling our State Representatives, Governor, and Congress people. Hopefully if we make enough noise a change will take place. If you think that this change isn’t affecting you so you’re not going to worry about it, think again. THIS IS GOING TO AFFECT EACH AND EVERY ONE OF US!

MS Blogger and Multiple Sclerosis Activist shares her journey living with MS, tips for others living MS and her husband, Steve, offers his insight as a caregiver for MS.