In the practice of medicine today, the sacred physician-patient bond is being broken. Health insurers' cost-driven decisions are overriding the direct relationships doctors have with their patients.

The Post-Gazette's April 1 story, "Switch To Generic Epilepsy Drugs Raises Flag," about the practice of switching patients from brand-name to generic drugs, alluded to the role insurance companies play, telling the story of a young epilepsy patient whose doctor switched him to a generic drug "because of insurance."

But the broader story of how patient care is being compromised in the name of profit needs to be told. Patients' long-term health often is compromised for short-term gains.

As a primary care physician with more than 20 years of experience, I have continued to watch how insurers' practices impede physicians' ability to care for their patients. Our autonomy is being eroded, and my patients, who come to me expecting to receive the treatment we mutually decide is best for them, often leave confused when they are denied that treatment.

Without question, controlling costs is important. But as a doctor, knowing a patient is being denied the best treatment because of an insurer's decision is troubling.

As insurance companies continue their move toward a standardized care model in which they strive for little deviation in treatment of patients who have the "same" condition, they seem to forget that physicians are not working with widgets. Patients are individuals and medicine is an art. It is not an exact science.

Insurers today can dictate which drugs to use because there is no evidence of significant benefits of one drug over another based on head-to-head trials. Drugs in the same class are generally thought to be therapeutically equivalent because of similar mechanisms of action. So, if you have high cholesterol, you may be prescribed one of any number of generic statins even though they have different characteristics and different patients metabolize them differently. It naturally follows, then, that substantial differences in patient outcomes may be expected.

This is just one example of how insurers are interfering with patient care.

Take prior authorization, a process that prevents a physician from prescribing a particular medication without prior authorization from the insurance company. Some of the most expensive medications are on the prior authorization list, and busy doctors will tell you that prior authorization is very much a hassle marked by paperwork and phone calls. Insurers are betting that a busy physician won't jump through their hoops to get the expensive drug. Unfortunately, in many instances, they're right.

Pay-for-performance programs are another misguided attempt by insurers to save money at the expense of patient health. In fact, many physicians call the program "pay-for-reporting," given that it's based more on medical claims data than patient outcomes. Doctors can be denied privileges, lose patients and lose patients' trust when insurers grade them with data that reflect who provides the cheapest care or who prescribes the most generic drugs.

Off-label prescribing is another instance in which insurers, not physicians, are making medical decisions for patients. In fact, last summer the Post-Gazette reported on this practice when it told the story of fibromyalgia patients who were being prescribed Lyrica or Cimbalta, the only two FDA-approved drugs for the treatment of the condition at the time, only to be denied coverage by their insurers. Many times, insurers will insist instead on other pain relievers or alternative treatments not approved specifically for a patient???s particular condition.

Part and parcel with off-label prescribing is step therapy, a process through which insurers require a patient to first try other therapies or drugs than the one prescribed by the physician. Only after this step therapy has been documented to fail at treating the patient will the insurance company approve the treatment originally prescribed.

Over the next several months, as the debate over health-care reform takes center stage, much will be said about making health insurance affordable and accessible. During this debate, there are steps that individuals can take to make it more likely that physicians remain central in ensuring that patients receive the best, most appropriate care, which is what patients expect and deserve:

• 1) Find out more about these issues and the Alliance for Patient Access (www.allianceforpatientaccess.org), a national network of more than 250 physicians with the mission of protecting patient access to approved medical treatments and therapies, including prescription pharmaceuticals, biologics and medical devices.

• 2) Sign the petition in support of the National Health Insurer Code of Conduct, which is being drafted by the American Medical Association. (It can be found at the Alliance for Patient Access Web site.) The code will address restrictive practices of the health industry that compromise the physician-patient relationship.

• 3) Write and call your elected officials and voice your support for the Four Pillars of Health Care: choice, competition, accountability and personal responsibility.

Quality health care that is affordable and accessible makes sense. Doing so at the expense of the physician-patient relationship does not.