Informed consent is a very important issue in healthcare these days. As patients are viewed more and more as consumers, they must be informed of all the details in order to make the best decisions for their own health. But, are insurance company formularies disrupting informed consent?
Before I prescribe a medication to a patient, I discuss all reasonable available options to them. We then explore which of these choices is the best for this individual patient. A decision is reached after the patient is informed of the most common and dangerous side effects. Once the patient concludes which path to follow, an electronic prescription or prescriptions are sent to the patient’s pharmacy. The office visit worked the way it was supposed to, with the doctor and patient being a team and arriving at an answer as to what is the most appropriate treatment.
However, this informed consent is tossed out the window when the pharmacy finds that this medication(s) is not available on the formulary of that patient’s insurance company. Often, it is too expensive to be paid out of pocket and an alternate medication must be interchanged. All is well when a medication from the same drug class exists on the formulary. But, sometimes whole classes of medications are not covered. This patient then receives a replacement medication from a different class that may have different side effects. The whole informed consent process that took place in the exam room is thus void.
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Patients are not going to return to the office to get the low down on this alternative medication. Instead, they will rely on the insert that comes with the medication or the internet. While these may be good sources of information, it does not replace the role of decision making that previously occurred and no true informed consent took place. The whole process was disrupted when the insurance company did not cover the medication that the doctor and patient decided on after a discussion as to risks and benefits. Anyone can surely see this is a sub-optimal practice.
Why do patients need to make informed decisions about their medications?
- They need to know the risks before they take it. No medication is without side effects and patients need to be aware of this before they start taking it.
- What may be an acceptable risk for one patient is not necessarily acceptable to another. We are not all equal risk-takers. A patient must be informed of the risks before going into anything and must be given the right to decline. Anything else strips the patient of their very basic rights.
- These days there is much poly-pharmacy going around. That is why these decisions need doctors to be joint decision makers in the process. We took an oath to do no harm. We must be allowed to tell our patients when something is too risky and they should avoid it.
- Insurance companies do not know what is best for patients. They do know what is best for their bottom lines, however. Their decisions of which medication to carry on their formularies, therefor, are made mostly out of cost considerations.
In order to give patients the dignity they deserve, they must be permitted to make informed decisions about their own health. When insurance companies step up and practice medicine on them, this strips away that humanity because they are no longer making informed determinations. Insurance companies have greatly disrupted the informed consent process in regards to medications. Patients need to retain the power over their own health.
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Dr. Linda Girgis MD, FAAFP is a family physician in South River, New Jersey. She has been in private practice since 2001. She holds board certification from the American Board of Family Medicine and is affiliated with St. Peter's University Hospital and Raritan Bay Hospital. She teaches medical students and residents from Drexel University and other institutions. Dr. Girgis earned her medical degree from St. George's University School of Medicine. She completed her internship and residency at Sacred Heart Hospital, through Temple University where she was recognized as intern of the year. She is a blogger for Physician's Weekly and MedicalPractice Insider as well as a guest columnist for HIT Outcomes. She has had articles published in several other media outlets. She is on the medical advisory board of SERMO. Recently, she has authored the book, “Inside Our Broken Healthcare System” and "The War on Doctors". She has been interviewed in US News and on NBC Nightly News.
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