Physicians Charge Insurer Caused Child's Suffering By Mandating Cheaper Generic Drug

BUFFALO, N.Y. -- A 7 1/2-year-old boy with cystic fibrosis landed in Children's Hospital of Buffalo with a bowel obstruction shortly after his insurer mandated substituting a cheaper, generic drug for the brand-name drug recommended and administered by his physicians.

His frustrated physicians consider this action and its repercussions blameworthy, and have even coined a term for it --"asfaliogenic complications" -- meaning medical problems caused by the profit-based decisions of insurers, which they introduced in a cautionary letter published in the March issue of Pediatrics.

The term is derived from asfalia, the Greek word for insurance. These physicians think it is a growing problem and that this boy's plight is not unique.

"An asfaliogenic complication is the natural course of a decision based on profit, not quality" says Philip L. Glick, M.D., associate professor of pediatrics and surgery at the University at Buffalo and one of the letter's four authors.

Staff at the local cystic fibrosis foundation made 25 phone calls and sent six faxes and 10 letters to the insurer protesting the change in medication for the boy, to no avail. Shortly afterward, the child developed a condition called distal intestinal obstruction syndrome, or DIOS.

"We suspect that this patient's DIOS was directly related to the inadequacy of the generic pancreatic enzymes that this third-party insurer, not his physician, recommended," his physicians state in their letter to Pediatrics.

"... a profit-motivated, business decision was made that directly affected medical care of a patient," the physicians write. "Insurers deny that their policy decisions are medical decisions. In their view, if a physician deems a treatment necessary, the patient should shoulder the cost, whether or not it is a covered benefit.

"In reality, many patients accept whatever medical care the insurer covers because they are unable to pay the additional out-of-pocket cost, and they trust that the insurer will adhere to the physicians credo, 'First, do no harm.' Asfaliogenic complications are inevitable when medical decisions are made by parties whose credo is, 'First make a profit'," they state.