Saturday, July 25, 2009

Rationed Care is Here: We Just Haven't Called It That


I have a family member who has an infection in his nail. The treatment for the infection is a pill that is taken for 3 months (with some liver function monitoring). It's not a fatal condition. He went to the doctor, got the bloodwork, waited for the results, then got a call from the doctor that he could start the medication and had the doctor call in the prescription to the pharmacy (CVS) next to his work. The pharmacy told him the medicine requires preauthorization. Even though there is not an alternative medication. The pharmacy called the doctor. The doctor filled out the preauthorization form. The form was sent in and it was rejected. The doctor called to say it was rejected and she didn't know why or what to do. She said the medicine is available at Walmart for $4 and offered to call it in there. She waited while the number for Walmart was located. She phoned the medicine in. She called back to say it was done. My family member didn't get the medicine at the pharmacy next to his office (where it cost $70 as cash, but likely has a negotiated lower cost to the insurance company plus his cash co-pay) and instead he drove 20 minutes each way to Walmart to pick up his $4 medication. The insurance company then spent the money on a 2 page personal letter and a stamp to inform him he wasn't preauthorized because the physician did not document that the condition was painful or uncomfortable and did not document that over-the-counter topical medications had been tried (they haven't been, but note, they take months to try and are known to be ineffective). The infection looks groddy, will not get better without treatment, and can spread, so treatment seems reasonable to me. There are no less expensive prescription treatments for this conditions and essentially no other options.

So let's see: 6 phone calls by the doctor
3 phone calls by the pharmacist (to the insurance, to the doc, to someone to say the preauth was denied)
A 2 page letter spit out by a computer but with some personalization as to patient name and drug name
A postal stamp and the involvement of several postal employees
40 minutes of driving by an executive with a top notch private health plan.
And the $4 prescription was had.

And we'll guess this amount of rigamarole saved the insurance company money by essentially bullying him into paying cash elsewhere rather than asking the doctor to fill out an appeal form and fax in "supporting documentation" for the appeal. How much did they save for the 3 months of medication they denied? Well $12 if they bought their meds at Walmart. If the insurance company actually paid the top cash price minus the copays, they saved an absolute max of $165 for 3 months at $70 (so $210) minus the $15 generic copays. My guess is it was somewhere inbetween, so was it worth it in terms of doctor time, pharmacist time, care manager time at express scripts, secretarial time for the appeal letter, mail carrier time, gas, and an hour of some busy's guy's life spent running around to get a script he could have gotten on his way back from lunch?

I don't have the answers, but I do know our system is broken. Many say it's broken only for the certain people....and really my family member got his medicine, and if the story got any more complicated, he would have just paid the $70, it's just the idea that they throw you through all these hoops because they can.

10 comments:

Anonymous said...

Dinah,

Not to get off topic, but I used nail gel for what sounds like a similar condition and almost totally cleared up my problem. It took about 1 to 2 months.

The only reason it didn't work 100% was I ran out of the substance and was too lazy to reorder it. I got it for free (long story) so I don't know how much it would cost although I am sure it was more than $4.00. But I would still use it instead of a med that requires liver function tests any day.

Back on topic - Imagine if your relative had a serious condition and was delayed by all the BS he went through. What if Walmart didn't have his prescription for $4, then what?

That is why I laugh when people say that single payer will ration health care. This is a perfect example of it being done already.

AA

The Girl said...

Wow, that is rough!

Retriever said...

Good post. Timely.

A middle aged relative (in what used to be called the prime of life) has been having hideously expensive eye treatments to delay the progress of a condition that usually only affects older people. Approved for use in the elderly. Not tested in younger people, because so few people get it. Without treatment, he will go blind.

We just heard that his appeal (after insurance company refused to pay, thousands per treatment, despite the fact that he has had multiple treatments, and they work) was rejected because "it is not medically necessary except in the elderly" (or words to that effect).

So I guess preventing blindness in an 80 year old is necessary but it's not for a person in their 50s? Needless to say, he will reapply, and go begging from the drug company, and if need be scavenge the money from somewhere, but this is crazy.

I have tried to cheer him up by reminding him that at least there IS a treatment, and that the family will find a way to pay for it, despite the hateful insurer.

But if his family were without insurance (as they would be if the breadwinner were laid off), they would have to choose between thousands of dollars a month for family members' maintenance meds and those eye treatments.

One point that is often lost sight of in the discussion by healthy people about how people can't expect insurance to pay for everything, is that if you have a few people with health problems in a family, the meds alone may cost more than the breadwinner's salary.

No one chooses to lose their eyesight. It is unrelated to diet except possibly eating too few vegetables high in beta carotene (I just had to get that in! As a veggie-grower with a veggie hating spouse), lifestyle, any known vices, or anything within a person's control.

Prevention doesn't work. Like many mental illnesses, this eye problem is genetic in origin, and just happens, and is too expensive for the average person to be able to afford to treat on their own.

My problem with the new push for health care "reform" is that it pushes the myth that "prevention" and non-specialist care will solve all our problems. This is not true of most psychiatric ills, and it is not generally true of the most serious and disabling physical conditions.

Incidentally, my parents did not seem to me to be getting the treatments and tests that would have been routine in this country during illnesses that proved fatal under the NHS in the UK. So single payer is not the answer. But the system we have now isn't working perfectly either.

I don't know the answers, just had to vent...

Anonymous said...

Retriever,

I am so sorry to hear about your relative. That is dreadful.

NHS is not what I had in mind regarding single payer. I am so sorry that your relatives didn't get timely treatment. I would like to hear more about it if you are comfortable sharing details.

I think Canada, while it isn't perfect certainly, would be closer to my ideal system. I haven't met any Canadians who would trade their system for ours.

And when we hear scare stories, there is always more to the story. For example, supposedly, a woman came to Mayo to be treated for a brain tumor that wasn't going to be treated right away in Canada. It turns out it wasn't cancerous and not life threatening. Not that that makes it minor but that kind of puts a different slant.

Many other Canadians who come to the US for treatment do it with the authorization of the government.

I am not minimizing your relatives' experiences by the way.

Just so you know, I have been excluded from health insurance thanks to a psychiatric history even though I am tapering off of meds and down to one. So something has to be done. I just don't think what Obama is proposing is the answer.

AA

gingerb said...

I had a similar problem and my Derm told me they didn't prescribe the oral mediciation because it can cause liver problems.

I dug the crud out of my toenail and put OTC cream on it for quite awhile, but not months and months, and it cleared up. Saved me potential liver damage plus those trips back and forth for blood work to monitor for it.

But, your point that anybody who thinks we don't already have rationing is valid.

I've had breast cancer, the "easy" in situ kind, and my provider doesn't do digital mammograms. I know from my on-line travels that some women in my situation get yearly digital mammograms plus MRI scans. Should I feel like I'm being shortchanged? The "standard of care" doesn't require digital images or MRI scanning. My treatments may fall short in cocktail party chatter, but they're not really sub-standard.

I had Rosecea and all I got was tetracycline, not the newer antibotics or a cream - which are way more expensive.

I'm still alive with decent skin and no life-threatening cancer so I guess it's good enough.

I think it's the concept of 'good enough" health care that frightens people who have coverage. It'd be a big improvement for those who don't.

Warner said...

Nationwide, prescription pills have become a societal force. Adults and children rely on them for a growing list of afflictions, including anxiety, depression, even shyness, for which few alternatives were available a generation ago. Nearly half of all Americans take at least one prescription drug. Meanwhile, direct-to-consumer drug marketing that touts new and expanded uses has become widespread. Adults and children alike are exposed to print, television and radio ads promising happier, more fulfilled lives. For young people, experts say, all these factors appear to have blurred the line between the benefits and dangers of the medications.

Midwife with a Knife said...

Hm... not meaning to be a curmodgeon here, but nail fungus is essentially a cosmetic issue. I mean, yeah, it is icky and contageous, but really not dangerous. (although I imagine it could be for diabetics, etc.. maybe).

the following comment is just a thought and not meant to detract from the ridiculous actions of the insurance company

But in a hypothetical single payer system, should we pay for diflucan for toenail fungus, or should that be up to the individual?

Anonymous said...

-1

ELN said...

As a 24 y.o. cancer patient who would be completely wiped out were it not for her parents' wallets, I can't understand why my Republican parents don't understand this. And the US with a mortality rate 2x+ higher than the Gaza Strip, no less.

Can't find the link, but there was a recent (not statistically valid) survey of Canadians and Americans regarding their satisfaction with the healthcare system. Overall, Canadians were more satisfied, particularly so when it came to those with chronic/serious illnesses.

And what is with these people who deny the possibility that just because universal healthcare was implemented poorly in a handful of other countries, we can't do it better? Mind you, these are the same people who think the US is the greatest country on earth and that we can do no wrong.

I don't claim to be smart enough to know all the answers or fix it myself, but it's time for us to stop sticking our heads in the sand and admit we need to try ANYTHING new.

Anonymous said...

Who knows how WalMart pulls off any of the crap that they do? They're ripping off Girl Scout cookies now. It's all cheap stuff from China that probably has horrible things in it that it's better not to think about. (I hope that's not considered slanderous.. slander has to be false, right?)

On a more positive note, neem oil is great for fungal infections. And viral infections, for that matter; it works wonders on cold sores. You can pick up a bottle on eBay for dirt cheap. My drugs professor always babbled on and on (and on and on) about the stuff. Be sure to mix it with lots of essential oil of peppermint, though--it smells horrible.