adult ADD treatment

November 18 2014

Sav-Rx reverses denial of effective Adderall XR dose for my adult patient

David W. Goodman, MD Doctor's Blog, Patient Education ADD medication, ADHD medication, adult ADD, adult ADD treatment, adult ADHD, help for adult ADD, help for adult ADHD, Insurance denial of ADD medication, Insurance denial of ADD treatment, Insurance denial of ADHD medication, Insurance denial of ADHD treatment

Sav-Rx reversed its initial denial of my patient’s Adderall XR 80 mg daily after receiving my letter of appeal. In my letter, I highlighted the stable effective dose had been prescribed for quite sometime. Their initial reason for denial was a citing that FDA approved max daily dose was 60 mg in the morning. In fact, the package insert for Adderall XR has no stated max daily dose for adults with ADHD. Fortunately for my patient, Sav-Rx reconsidered its decision. See below for my original blog describing the situation.

With an increasing number of adults being nearly diagnosed with ADHD, the expense of ADHD medications for insurance companies has escalated. While the annual prescription increase for childhood ADHD is less than 3%, the ADHD prescription market is growing at approximately 10% per year. As a result of this change, companies are under increased pressure to reduce their pharmacy expense. While this issue is certainly not limited to ADHD medication, my patients are finding the course of the medication treatment disrupted by insurance companies obstructionistic prior approval requests for long-acting stimulant medications.

Patients and their treating physicians may struggle for some time to find the most effective individualized medication dose that produces an optimal reduction in symptoms with tolerable side effects. Patients have recently found insurance companies changing their coverage of authorized medications. That means, that despite prior approval for your current medication, the new coverage change may no longer authorize the medication and/or dose. This is becoming extremely disruptive to my patients finding themselves forced to change medication because of high deductibles, leaving them paying hundreds of dollars a month for their prior effective medication.

To give you a specific example, SavRx, a prescription management service in Fremont, Nebraska, informed my patient who has been treated with Adderall XR 80 mg in the morning for the past six months that the coverage for this was no longer available to her, despite the fact that it had been approved by the previous pharmacy management company. Having submitted the documentation of effective treatment for months, SavRx is still not approving her optimal dose.

My recent experience indicates that this approach to medication authorization is increasing in frequency across several companies. I will continue to post blogs giving examples from other companies.

My suggestion to patients who encounter this issue with their treatment is to call your insurance company and complain about your specific case. The insurance companies may not be aware of what is happening and they certainly don’t want unhappy subscribers, let alone bad public press. We will soldier on.

September 15 2014

CVS/Caremark deny prescription for bogus reason

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With each passing day, I encounter an increasing number of obstructions by insurance companies to authorize and provide my patients with their much needed medication. In my last blog, I highlighted Sav-Rx bogus reason to deny my patient the authorization to continue effective medication because of a change in policy coverage despite being on this dose for over 6 months .

Today, I’ll highlight CVS/Caremark’s explanation for “canceled” prescription to a patient who was on Vyvanse 70 mg in AM but needed to reduce the dose to 60 mg in the morning because of difficulty falling asleep. Here is the quote for canceling the 60 mg prescription sent to them.

“We were unable to fill this prescription because taking it is not advised based on your allergies, health conditions or potential interaction with another drug you are taking. Please contact your prescriber for assistance.”

While you might think there is legitimacy in this reason under the guise of safety, the fact is that the patient has been on Vyvanse since 2008 and there has been no clinical relevant change in his treatment that merits CVS/Caremark’s reason.

Such denials under the seeming auspicious of patient safety seem to be nothing more than denial of coverage for cost containment, in my opinion.

I encourage patients to call insurance companies and complain. When that doesn’t work, file a one page complaint with the State of Maryland Insurance Commissioner’s office. This office needs to be aware of the denial of treatment by insurance companies with regard to medication treatments for ADHD.

I intend to post more examples of such denials by specific companies along with the quoted explanation of denial. Perhaps someone with influence over this issue will find these examples ample evidence to formally question the insurance coverage of this and other medical treatments.

October is National ADHD Awareness Month and this issue should be part of the discussion. Please make your comments here so I can see if I’m hitting a nerve.

July 16 2014

ADD stimulant substitution by insurance prohibited in Maryland

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Step therapy is the requirement that a patient first try less costly medication before being prescribed medication a doctor thinks is best for the individual patient and specific symptoms/history. In the recent past, insurance companies had requested that adults with ADHD first be treated with a short-acting stimulant despite the fact that no short-acting stimulant is FDA approved for the treatment of adult ADHD. More recently, many insurance companies request “prior authorization”. This is a paperwork process to see if the patient can be directed to less costly medication despite the fact that the “recommended alternative” may not last long enough during the day. I’m relieved now with the passage of a new law in Maryland that will prohibit this practice. The following text appeared in the Maryland Psychiatric Society newsletter May 29, 2014. MedChi is the state of Maryland medical association.

MedChi applauds the enactment of SB 622/HB 1233, a bill that addresses a dangerous health insurance practice known as “step therapy.” Step therapy (or “fail first” policy) jeopardizes patient health by requiring them to try and fail on up to five older, less effective treatments before the insurer will cover the treatment originally prescribed. This law protects patients and keeps treatment decisions in the hands of doctors. The Maryland Health Care Commission recently studied step therapy, and Senator Middleton and Delegate Bromwell introduced this bill to codify some of its recommendations. The Middleton/Bromwell legislation, which takes effect on July 1, prevents insurers from forcing patients who are already being effectively treated on a medication to undergo the step therapy process, and also prohibits insurers from forcing patients to try medicine the FDA has not approved for treatment of a specific condition. Maryland is the first state in the country to enact the latter provision. Evidence suggests that step therapy may increase overall health care costs. Patients forced to manage multiple insurer “steps” often endure additional trips to the doctor or pharmacy, with additional time off from work or child care. When patient treatment is unnecessarily delayed, manageable conditions can devolve into more difficult to manage diseases. From May 5 MedChi News

I encourage my patients, their family and all those for who this applies to actively pursue and receive the most effective treatment and medication that works for them. And then let your insurance company know that you are an informed patient who will advocate for your legal right to individualized treatment.

Hope this is useful to you.

January 28 2014

WYPR interview on ADHD with Dr. David W. Goodman

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My discussion with Dale Archer, M.D. (psychiatrist, best-selling author) on WYPR September 27, 2014 about ADHD, over- diagnosis, and over-prescribed medications was lively. While Dr. Archer advocates “medication as a last resort” and “the goal of treatment is to get off medication” after learning new skills, I offered the research on medication benefit and a quality of life measure to evaluate medication utility. Certainly, treatment of ADHD at all ages incorporates behavioral therapy, organization skills, couple/family/individual therapies, and academic/occupational accommodations, in addition to medication, when indicated.

For those of you interested, the radio broadcast is available and runs 35 minutes. I invite you to listen and decide for yourself the merits of each position. Ultimately, this information best serves those who have ADHD and their families.

January 16 2014

Dr. Goodman interview on Dan Rodricks show on WYPR Jan 27 at 1pm

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I have been invited as an expert on ADHD to participate in an interview on the Mid-day with Dan Rodricks show on WYPR on January 27 1-2pm. This is a live panel discussion that will include Dale Archer M.D., a psychiatrist and writer, to discuss the use of medication and treatment options for ADHD. The discussion is moderated by Dan Rodricks who is a distinguished journalist in Baltimore with a regular feature in the Baltimore Sun newspaper.

Dr. Archer wrote an article online for Forbes on January 6, 2014 on his perspective of ADHD and the overuse of medication and the over-marketing of ADHD. His article highlights and echoes the sentiments of Alan Schwatz in his New York Times article “The Selling of Attention Deficit Disorder” published December 15, 2013.

This one-hour program will give me the opportunity to highlight the national and international scientific literature and research on ADHD. I hope to highlight the well documented negative consequences over the course of one’s life with untreated ADHD as reflected in several international prospective studies following ADHD children into young adulthood.

This program promises to be a lively discussion and offers listeners the opportunity to call in with questions. I encourage you to mark your calendar. I believe the program can be accessed online. If you listen, please leave me your comments for feedback.

December 28 2013

“The Selling of Attention Deficit Disorder” The New York Times December 15, 2013

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The New York Times article “The Selling of Attention Deficit Disorder” published December 15, 2013 had quoted me towards the end of article. As I had previously written in my blog posting, the quote was taken out of context and deliberately misrepresented my professional article with Medscape. I did send a letter to the editor in order to have this quote placed in appropriate context, however, in the letters to the editor, it went unpublished. So, I’ve posted my letter to The New York Times here.

The New York Times

Letter to the Editor

December 14, 2013

Dear Editor:

Let me congratulate Alan Schwartz on his extensive review of ADHD in his article “The Selling of Attention Deficit Disorder”, December 14, 2013. He highlights the increased identification of people with ADHD and the growing use of medication as a treatment option. Unfortunately, he presents information that malign physicians and researchers who have committed their life’s work to investigating the causes of ADHD and pursuing research to prove treatments effective. Mr. Swartz would have served his readers well by revealing his a priori agenda in writing this article. A case in point, Mr. Schwartz quotes me in regards to an article I authored for Medscape on adult ADHD. In this article, he knowingly and deliberately eliminated my notation that the six-minute video accompanied a 2000 word article with 86 scientific references that extensively detailed the clinical evaluation process for ADHD in adults. Therefore my quote, out of context, misrepresents my work and misleads your readers. Perhaps his article would have been better placed in the Op-Ed section of The New York Times.

David W. Goodman, M.D.

The moral: Discern the agenda of the journalist before you make sense of the information provided. As I like to teach my psychiatric residents at Johns Hopkins, the credibility of the information is a function of the intent of the provider.

December 17 2013

Dr. David W. Goodman featured as ADHD expert in The Washington Post article’s December 17, 2013

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The Washington Post took the initiative to write an article in today’s (December 17) paper on ADHD in adults ages sixty and older. This article is also accompanied by a sidebar article discussing adult ADHD Older adults with ADHD are a group that has not been specifically researched and about whom very little is written. The Washington Post article includes two or three people with ADHD who were diagnosed much later in life. They speak about their lifetime experiences with untreated ADHD and the positive change they and others have noticed with treatment.

Imagine that you spent 60 years of your life distracted, disorganized, forgetful, and chronically tardy. Imagine that you have dropped out of school, lost jobs, or were divorced as a direct consequence of that state of mind. Imagine that you seek help from a professional and you are told that you have a disorder that can be effectively treated. Imagine your reluctance and hopefulness that these experiences can diminish. Imagine that you agree to treatment and discover that all of these experiences were symptoms of the disorder and not you as a person. I know, that’s a lot to imagine. At this age, the goal of treatment is not only to treat ADHD but to help a person understand the difference between what they have (disorder) versus who they are (person). In my experience helping people, this process helps resurrect a person’s self-image.

I invite you to read these two articles and seek professional help if these symptoms resonate with your experience. If you are an older adult with possible ADHD, I recommend that you see an expert in ADHD who will be able to make an accurate diagnosis. Because older adults may have both medical and psychiatric disorders in addition to taking medications, it’s critical that an expert be able to distinguish multiple disorders and evaluate the presence of ADHD accurately. Effective treatment is completely dependent on the accuracy of the diagnosis.
Thank you for your interest.
David W. Goodman, M.D.

December 15 2013

Dr. David W. Goodman quoted in The New York Times Today (December 15, 2013)

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Today the New York Times published an article “The Selling of Attention Deficit Disorder” by Alan Schwarz. This is a lengthy article highlighting the increased identification of people with ADHD and the concomitant increase in the prescriptions of effective medications. The article is a feature story on the New York Times website today.

Toward the end of this article I am quoted for the authorship of a continuing medical education article I wrote for Medscape.com in August 2012. In the Times article, he references a six-minute video clip of an interview between physician and patient I had included in my Medscape article. He uses my quote “That was not an acceptable way to evaluate and conclude that the patient has A.D.H.D.” to indict me for using the short video as an example of how to evaluate adult ADHD. He sat with me for 30 minutes in Washington DC and recorded our interview. However, what he failed to mention in his New York Times article was that the video clip he referenced accompanied a 2000 word continuing medical education article with 86 scientific references that was estimated to take physicians 2.5 hours to complete. It would appear that Mr. Swartz had an a priori agenda in presenting his information. His remarks in the article malign and misrepresents physicians’ and researchers’ commitment to exploring causes and effective treatments for ADHD. Unfortunately this is not my first experience with journalists dispensing with facts that don’t support their biased premise.

This evening I composed my Letter to the editor and have forwarded it to them. Let’s wait and see what develops. And now you have the back story to my quote. Thank you for your interest.

David W. Goodman M.D.

May 18 2013

Nondrug ADHD treatments not very effective

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I was recently invited to write an editorial for an international medical journal on a study by Sonuga-Barke and colleagues. This published study was an extensive review and analysis of published research looking at several different nondrug treatments for ADHD. My editorial will be published by the British Medical Journal in Evidence-based Mental Health June 2013. Dr. Sonuga-Barke’s analysis looked at 2904 studies of which 59 were selected because they satisfied high-quality data. I’m unable to provide my editorial text as the manuscript is embargoed until publication.

Dr. Peter Yellowless briefly reviews the study conclusion in a Medscape video.

The study divided treatments into several categories: restrictive elimination diet, artificial food color exclusion, free fatty acid supplementation, cognitive training, neurofeedback and behavior interventions. Only artificial food color exclusion and free fatty acid supplementation were statistically significantly effective, although the effect was relatively small.

Single clinical trials are often published showing some positive benefit. These studies then receive media coverage, especially if published in high impact journals. However, publication bias exists because negative studies often don’t get published, leaving readers with a false sense of benefit.

Publications like Dr. Sonuga-Barke’s help doctors and patients review multiple studies to see if replication of positive findings occurs. Evidence-based medicine in not based on single study reports but on the accumulation of studies over time.

As I like to say “On the highway of opinions, let science be the designated driver.” David W. Goodman, M.D.

May 12 2013

Finding ADHD Experts Around the World

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Because my patients travel from the U.S. or come to consult me from other countries, the question of locating experts in ADHD, especially for adults, comes up often. Here is my suggestion to locate such an expert.

Go to www.pubmed.com. This is the National Institute of Health website on medical publications.

In the search box, enter “ADHD” and the city and/or country in which you seek an expert.

Several publications will come up with authors in your designated location. Find one that is relevant, Open the link and you will see a summary of the publication.

The first author will often have an academic affiliation whose geography you can check. The first author often has his/her email address listed. You can email the author and ask if he/she sees patients or to whom he/she would refer someone for evaluation and treatment of ADHD.

You may have to go through emailing a few people to get to someone with the expertise you seek and is currently seeing patients.

Simple and effective. Hope this helps those who stumble across this blog.

David W. Goodman, M.D.