Wednesday, August 05, 2009

Treating the Cosmetic

I wrote a post about the hurdles one of my family members had getting insurance authorization for a medication for an infected nail. He surrendered and bought the medication at Walmart for $4 as the insurance company would not pay for the medication: the doctor had not indicated that the infection was causing pain or discomfort and so treatment was not approved-- of note, this doctor had never been denied this preauthorized medication for a patient before and was not aware he needed to specifically say the infection was causing pain or discomfort . Blog reader and physician Midwife With a Knife commented that onychomycosis (fungal nail infections) are really a cosmetic issue: should insurance even pay for such things?

It's an interesting question as to what constitutes distress and discomfort. ClinkShrink and I had a series of posts on the Worried Well and who deserves care-- we got close to bloodshed a few times, actually. Is one state of subjective distress more worthy of insurance-treated medications than another? Evidence-based medicine, FDA approvals for specific illnesses, and all that jazz, but as psychiatrists we sometimes see patients who don't do the best job of articulating their distress-- is it only real and worthy of certain treatments if you can articulate your torment in the right words (and perhaps the answer is yes)?
If your groddy toenails bother you, or leave you feeling self-conscious in your designer flip-flops, should insurance pay for your meds? Since there's a $4 Walmart option, maybe it shouldn't. And how does Walmart get all those meds so cheaply?

If you have a huge and ugly-- but benign-- lesion on your face, should insurance pay for its removal? And what constitutes "discomfort"? Many people suffer from psychiatric disorders where the result is subjective distress, but not dysfunction or impairment. If you're quietly having panic attacks, but they don't impair you, should your insurance pay for the treatment? What about a nose job if your nose is really ugly and attracts a lot of attention? How about breast or penile reconstruction for cancer survivors (or landmine victims, or the relatives of Ms. Bobbit?)? And what if you have pain, and repeatedly present to a doctor or the emergency room, and no anatomical cause can be found? Just thought I'd ramble about the lines of where we think about sticking our health care dollars...