“It was so bad. It just wouldn’t quit.” Sara, a new patient, was sitting in my office describing a migraine attack that had led to a recent hospitalization. Except it wasn’t exactly the migraine that led to hospitalization. It was, I found out, an attempted suicide, prompted by the relentless impact of chronic migraine.
Sara felt hopeless and helpless due to persistence of severe, refractory migraines. She felt she had become an unfair burden for her husband. “He has to do everything,” she explained. “All the work, all the housework. We can’t go anywhere or make any plans; I can’t work or help with finances. I can’t even do the grocery shopping,” she lamented. “We used to have so much fun.”
When I saw Sara, she had begun counseling and was no longer suicidal. So now it was my job to help her find a treatment regimen to address her migraine and restore her quality of life.
She had tried refractory and standard therapies, including various anticonvulsants, antihypertensives, antidepressants, botulinum toxin, acupuncture and peripheral nerve blocks. She’d even tried a myriad of short-acting acute therapies, including triptans, NSAIDs, analgesics and opiates. None worked. Sara was skeptical that anything would ever work.
I proposed a plan combining three different medications: a monthly CGRP-inhibitor injection as a preventive treatment and two different acute rescue medications from two separate classes. All are FDA-approved for her diagnosis, and all typically require prior authorization from insurers. I gave Sara samples of all three so she could begin treatment immediately. Meanwhile, I initiated the prior authorization process.
Sara returned for her follow-up a month later. She described significant symptom relief but had the same dour demeanor. None of her medications, it turned out, were approved by her insurance. The out-of-pocket cost of just one of the medication topped $2,000 a month — an expense that Sara couldn’t afford.
I gave Sara another month of samples and filed three separate appeals. The manufacturers of all three medications have safety net programs that help commercially insured patients whose health plan denies coverage, so I contacted them too.
Sara returned another month later, describing continued clinical improvement and continued frustration that she’d been unable to fill her prescriptions. In one case, her insurance was excluded from the manufacturer’s safety net program. She couldn’t get a call back from another aid group. She was hopeless, again.
Sara’s case exemplifies the disappointment caused by the way many health plans treat patients. Sara’s disease had disrupted her life, threatened her marriage and even pushed her to attempt suicide. Yet, given the promise of effective treatment, Sara still couldn’t get her health plan to approve the medicine that worked for her.
What’s frustrating for health care providers like me is that patients like Sara sit across from us every day. We can see what the patient needs, and that the sample medications are working. Regardless, a blanket insurance policy dictates whether or not she’ll get what I’ve prescribed. Many patients may not possess the fortitude or ability to advocate for themselves. Similarly, not every health care provider can find the time to complete endless forms, pull records and make calls.
In the end, a combination of assistance programs, successful appeals and liberal samples have gotten Sara through. She and her husband even went out dancing a few nights before her last visit. To keep treatment within reach for other patients like Sara, though, health insurers need to re-think the barriers they erect between people with migraine and life-altering medications.
Heather McCoy, DRNP, is in private practice in Scottsdale, Arizona, where she focuses on the complex needs of adults and adolescents with headache disorders.
This post is part of IfPA’s “By All Accounts” blog series. Each month, a different guest author – and a different story – adds a new piece to the common narrative of how insurance practices meant to control costs are instead hurting patients.