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Physicians Still Waiting for Flexibility in Prescribing to Suicidal Patients

April 16, 2020
By Madeline Peltzer

After publicly calling attention to the problem eight years, physicians say there has been little to no change in the way insurance companies cover prescription medications for suicidal patients considered in danger of a drug overdose.

In 2012, the American Psychological Association (APA) stated “pharmacy benefit management companies should offer prescribing physicians flexibility in determining when dispensing of an entire 90-day supply of a medication is clinically dangerous and should offer alternatives that would enable dispensing a 90-day supply in multiple shipments without financial penalty.”

Insurance companies began promoting 90-day supplies in the belief it would improve patient compliance with their drug regimen and save money because it would cut dispensing costs and allow pharmacies to buy drugs in bulk.

Giving a three-month supply could be problematic, however, for patients in danger of drug overdose.

“Physicians must make repeated phone calls and faxes, diverting valuable time away from patient care,” wrote Brian Barnett, M.D., a Cleveland, Ohio-based psychiatrist, in The Wall Street Journal on February 6. “Few insurers have streamlined processes for physicians to obtain insurance coverage for small medication quantities.”

In addition to suicide, physicians are concerned about the potential for addiction when giving patients larger amounts of prescription drugs, says Merrill Matthews, a scholar at the Institute for Policy Innovation and a policy advisor to The Heartland Institute. “I have heard doctors complain that they plan to prescribe, say, a 30-day supply of a pain reliever after surgery, but then be pressured to make that 90 days, even if there is no justification. That opens the door for abuse.”

Overdose Deaths on the Rise

A 2018 Centers for Disease Control and Prevention report found the age-adjusted suicide rate increased by 30 percent, to 13.5 per 100,000 people, in the years 2000-2016. Suicide is the 10th leading cause of death in the United States. Although suffocation and firearms are the most common means of suicide death for most age groups, male and female, suicide by drug overdose is significant, especially for older females.

Accidental drug overdoses are also on the rise, in large part resulting from the opioid crisis, but determining whether an overdose is accidental or an act of suicide can be difficult. “Without psychological/psychiatric evidence contributing to manner of death classification, suicide by drug intoxication in the U.S. is likely profoundly under-reported,” states a January 2018 report by the National Center for Biotechnology Information.

Offers Free Market Approach

The concern about overdose deaths points to the need for greater personalization in medical care and health insurance to empower doctors, says Robert Emmons, M.D., a psychiatrist and policy advisor to The Heartland Institute. 

Under the current system, insurers, employers, and the government pay the vast majority of medical expenses. As the ones footing the bill, large organizations decide what they will cover and how much they will pay.

“In general, any third-party involvement whatsoever in the specifics of clinical decision-making, such as quantities of pills dispensed, is problematic,” said Emmons. “Third parties always represent interests other than those of individual patients. Always.”

A free-market approach to coverage would allow consumers and their physicians to decide the best course of treatment, says Matthews.

“Drug companies depend on the prescribing doctors, who are the check-and-balance in the system,” said Matthews. “They are the only ones in a position to determine what's best for their patient. They need to be able to tell the dispensing pharmacy what their patient needs, and no more.” 

Madeline Peltzer (mpeltzer@hillsdale.edu) writes from Hillsdale, Michigan.

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