One of the standard conservatarian responses to anyone suggesting government-funded universal health care is to start talking about how universal health care will inevitably lead to faceless, heartless bureaucrats denying or delaying treatment for stupid reasons. My response to these stories is “Who’s supplying your health insurance? And how do I get on that plan?”

Through my employer, I have a pretty generous health plan, administered by one of the most highly-regarded health insurance companies in the region. And this week, for the second time in two weeks, they refused to cover my prescription for heartburn medication.

(Details below the fold.)

I’ve been taking Nexium for a while now, since my regular doctor prescribed it back in February, and when I was still having problems, the gastroenterologist gave me a bag full of sample bottles, and told me to start taking it twice a day. At the follow-up visit after my endoscopy, I was told to continue that for the foreseeable future, and given a new prescription for a month’s supply of pills, with instructions to take two a day.

A little over a week ago, I took the prescription to my local chain pharmacy, and they said it wouldn’t go through. My insurance company refused to pay for the pills, because it was too soon for a refill of my prescription. I pointed out that this was not, in fact, a refill, but rather a new prescription, and that made no difference. The computer said they wouldn’t pay, and I couldn’t get it filled until this past Friday.

I forgot to call them on Friday, so I stopped by Saturday morning, and asked them to run the prescription through. Again, it was denied. Their computer says it’s a once-a-day drug, and they won’t pay for two pills a day. I pointed out, again, that this was a new prescription that clearly (well, as clearly as you’ll find on a prescription pad– do they teach lousy handwriting in med school?) stated that I was to take two pills a day. Again, it made no difference. They wouldn’t cover it without explicit authorization from a doctor.

Which means, I have to call my doctor, and have him call my insurance company to authorize the prescription, and then I have to go back to the pharmacy, and ask them to run the prescription one more time. Probably more than one, because I’m sure they’ll take a day or two to process the approval, and God knows, they won’t call me to tell me when it’s done.

Now, I don’t actually object that much to the idea of the insurance company keeping track of prescriptions to prevent people stockpiling medication on their dime, or buying lots of cut-rate Nexium to distill into… whatever you can make out of Nexium. That’s a perfectly sensible cost-control measure.

What I object to is the fact that they’re making me do their job for them. It’s perfectly sensible for them to screen prescriptions to avoid frivolous expenses, but they’ve got phones, and computers, and employees whose whole job is processing health care claims. My doctor’s phone number is right there on the prescription pad, and I’m sure it’s in the pharmacy computer– the insurance company ought to be able to call the doctor themselves, and confirm that it’s a legitimate prescription, and approve the payment that way.

But that’s not what they do. Instead, they make me call the doctor, which is always a multi-step process of leaving messages on voice mail systems, and sitting around waiting for them to call back. And then, the doctor has to call the insurance company (more sitting around waiting on voice mail), and then I have to call or go to the pharmacy again. This is all time taken out of my day, and none of this is part of my job. It ought to be part of the insurance company’s job, but they’ve got me over a barrel, because I need those pills, so even though it’s a pain in the ass, I’ll make the calls, and waste a bunch of time sitting around my office playing phone tag. (Luckily, I have a job that has enough flexibility in the schedule to let me play phone tag during business hours– lots of other people don’t have that luxury. Which, of course, is probably another source of savings, as some of them will end up going without the medication…)

(While we’re noting ways I’m lucky, this isn’t life-threatening, and if it were, I could afford to buy the pills and get reimbursed later. And I’ve still got a sack of sample bottles, so I haven’t missed a dose yet. It’s the principle of the thing.)

Keep in mind, this is one of the best insurance plans in the area. I hate to think what the lousy companies do to their customers.

So, if you say to me that universal health care will involve faceless bureaucrats delaying or denying necessary treatment, my reply to you is, “Welcome to my world.”

Comments

  1. #1 Lou Betty Rood, Ph.D, D.O.
    April 10, 2006

    I recently retired as a family doc (Ph.D. in human genetics and a D. O. from MSU.) Nexium is a way for the company to get way too much money for a drug that has no clinical signifigance when coompared with Prilosec, which is available in generic and for which the insurance company might not give you so much hassle. Nexium is a stereoisomer of Prilosec, but the key carbon atom has no effect on the chemistry you are interested in, it just extended the patent.

  2. #2 Bill Hooker
    April 10, 2006

    In fact, Prilosec is available OTC; my wife says it’s $30 for 42 tablets, or ~$0.71/day (maybe $1.40/day for you if the dose is the same as your Nexium). I don’t know whether you can even get a scrip for OTC meds, but we don’t bother because the potential savings are not worth the hassle of dealing with her asshole HMO.

  3. #3 Roman Werpachowski
    April 10, 2006

    Chad, I live in the country where there is universal health care. Nothing pleasant: doctors earn as little as $200 a month (I earn 2.5 times as much), queues are long and corruption is rampant.

    You tell me that Poland is poor — I agree. Ask the British, then, how they feel about their state-run NHS.

    The moral? There is no perfect health care system. It is necessary to have some market economy in health care, otherwise costs skyrocket because patients and doctors “work the system”. It is also necessary to control this market, because otherwise the suppliers use the assymetry of information to their benefit (when was the last time when you chose your treatment by yourself?). It is also necessary to have some state funding, because otherwise some people are left outside without even a basic care.

    The trouble is how you mix the ingredients. AFAIR, America makes up for the deficit of the universality in its health care system by a large system of charities. When my uncle was an illegal worker in the USA in the early nineties, he had a complicated brain surgery done for him in New York by a charity — for free. He only had to pay for introductory medical checks. He had no insurance, no Social Security, no job permit. An illegal alien. I don’t think this could happen anywhere in Europe right now (or in the present USA, given more strict controls over immigration).

    Even if your work out everything, some people will complain, because everyone honestly thinks he has divine right to the best health care available at the moment. Or if not him, then his spouse/children certainly do. But then we would spend 100% GDP on health care.

  4. #4 Anon
    April 10, 2006

    Actually, if you ask the people of Britain how they feel about the NHS, the answer you get is highly dependent on the way you phrase the question. If you ask them how they feel about the NHS as a national health care provider, they will talk about waiting times and other things they see in the paper. If you ask them about their personal experiences of the NHS, they generally efuse about the quality of care. If you ask whether they want to keep the NHS or adopt a different model of healthcare, they almost universally want to keep the NHS as it is. Unfortunately, no links to these facts, but they come from ‘market-research’ I commissioned to ask just these questions on behalf of a former employer.

    Now I’m a faceless bureaucrat who tries to decides which services are offered by the NHS. The process is probably not dissimilar to that which goes on at insurance companies, but with greater emphasis on effects rather than costs, and a requirement that all have equal access. You’d never have to worry about filling your prescription here, becuase the GP would only be able to prescribe from a fixed list, and the pharmacy would only charge you 6.50, regardless. As long as it is on the list, the pharmacist gets re-imbursed.

  5. #5 dlamming
    April 10, 2006

    What the first commenter said about Nexium. To quote:

    Tom Scully, the US federal government official in charge of Medicare and Mediaid, told doctors at a conference, “You should be embarrassed if you prescribe Nexium.”

  6. #6 Sean Hederman
    April 10, 2006

    There is another reason besides simple cost-cutting to not allow a refresh of a medicine before it’s run out. It’s quite simply that overdosing on the medicine, as many people do, can sometimes lead to serious medical complications down the line. Fair enough, this is cost-cutting too, but not really one we should complain about ;-D

    Many medical aids in the past have made the mistake of denying medicines and then having to pay for expensive hospitalisation, as a result they tend to be much more circumspect about denying prescriptions these days.

    However, I cannot see any reason for the health care system not to fill a doctors prescription once the “original” has run out, even more so given that it was a specialist who provided the prescription.

  7. #7 Chad Orzel
    April 10, 2006

    Re: Nexium, I’m not particularly surprised that it’s the same stuff as Prilosec. I do know that the prescription dose is double what you can get OTC, so to match the Nexium dose, I’d need to take four times the amount of Prilosec daily.

    As I said, I’ve got a bag full of sample bottles, and the doctor offered to give me more of those, so I’m all set. Longer term, once the insurance approves it, I’ll only have to pay the $10 co-pay, so the cost doesn’t really hit me directly.

    Of course, approval from the insurance company can apparently take up to five days from the time that the doctor’s office calls it in. So, as far as I’m concerned, they can shell out the extra bucks for Nexium, just because they’ve pissed me off.

  8. #8 candace
    April 10, 2006

    Speaking as someone who has dealt with healthcare in the US and in the UK: The NHS is ace. Another anecdotal data point. Or two if you count my husband.

    Seems like American media is always playing up the “we hate the NHS” side of things over here, when, by and large, that isn’t true at all. When the NHS fails us, as the populace of the UK, we don’t want to kill it and have private-only healthcare, instead we are concerned and want to fix it. Right now, we are simultaneously proud but deeply concerned about funding issues.

    Personally, I’d take a broken NHS over no state healthcare at all any day.

  9. #9 Spotted Quoll
    April 10, 2006

    In Australia the Medicare system of national health insurance is much beloved by the population, despite the increasingly serious lack of resources. Woe betide any pollie who tries too obviously to kill it off, though they might succeed by stealth.

    And just to rub our faces in the under-resourced Medicare system, the long-serving conservative federal government here has some bee in their bonnet about getting us all onto private insurance, which is proving just soooo popular that the government has to offer a THIRTY percent rebate on the private health premiums, and still people leave private insurance schemes in droves, and the insurance companies frequently ask for premium increases.

    I have worked in both public and private components of the Australian health system. And my opinion on private health insurance? Bah, humbug.

    I ain’t no socialist, just a realist who knows from long experience that the private sector simply cannot deliver on this crucial issue. The private sector has an important role in medicine, but not as the primary insurers, that role is best filled by government.

    Nuff sed.

  10. #10 Steinn Sigurdsson
    April 10, 2006

    I’ve experienced the US, UK and scandinavian health care systems, and in the US have had quite good health insurance, such as it is.
    NHS is much better overall than anything I have seen in the US, on most fronts. Few things done better in the US, especially anything involving gadgets and lab tests, if you are in a developed area.
    US health care system seems to be perilously close to large scale failure and suffers from multiple perverse incentives and negative externalities.

  11. #11 Dan R.
    April 10, 2006

    You might want to ask your doctor about prilosec generic which is available via prescription at the same dosage as Nexium. Generally, the drugs are the same, but some people react differently (different side effects). With all the problems you are having, and your dosage, I wouldn’t switch w/o talking to your doctor though.

    Something to think about though — you might consider switching pharmacies. At least in my area, most pharmacists (or their employees) will guide a script through the Prior Approval process — making the phone calls, getting the authorization, dealing with the doctor’s office, etc.

    As for the US health system — you would be hard pressed to find anyone currently involved in the system who actually thinks its a good thing. In addition, most providers realize that HSA’s are worthless for purposes of expanding care and holding down costs, and that eventually some sort of universal scheme will be needed.

  12. #12 Mike Kozlowski
    April 10, 2006

    Man, don’t talk to me about the awesome efficiency of the insurance industry. I’ve never — not once — gone to a doctor and had the insurance company take care of it properly. My favorite was the time where I had to make a dozen coordinating phone calls between the doctor and the insurance agency about whether or not everything had been sent out, finally to have the insurer say, “Oh, they sent it to our LOUISVILLE office, and they need to send it to our Minneapolis office.” Because inter-office communication is impossible in the twenty-first century, obviously.

    Our current insurer appears to have a policy of automatically rejecting all claims “because we’re not sure if you have other coverage,” never mind that they’ve been our only coverage for three years now.

  13. #13 Jordin Kare
    April 11, 2006

    I’ve also recently been annoyed by the “no refills until 3 days before your prescription runs out” rules, since I tend to be traveling for more than 3 days at a time about every other week. But I’m not taking anything where missing a few days will be catastrophic. Still, it seems to me to be wise (where safely possible) to keep a small reserve of any drug you take — in your case, those samples. (Of course, always take the oldest pills first, and keep the freshest ones in your reserve…).

    On the more general issue of health insurance — I’ve argued for years that part of the problem is that “health insurance” as argued about in the US is really three very different things lumped into one: basic care delivery, real insurance, and end-of-life coverage. Basic care delivery is what the US totally screws up — I personally think it’s a duty of any reasonably wealthy society to provide basic care to anyone, and even in strict economic terms it’s insanely wasteful to have people without insurance using emergency rooms for basic care (or not getting it, and ending up with far more serious problems), not to mention the zillions of hours spent on paperwork.

    Real insurance, for rare-but-major health catastrophes, US private-insurance-plus-gov’t-plus-charity does pretty well, I think, though it’s gonna get weird as genetic testing and similar advances mean private insurance will be steadily more able to predict individual risk and charge accordingly.

    End-of-life care is already heavily a gov’t service in the US, and is the scariest piece in terms of economics, because there’s no obvious upper limit to the demand for it, or the ability of technology to create new and expensive therapies.

    What do we do about it? Damned if I know, but it would help if we’d only try to fix one problem at a time.

  14. #14 Roman Werpachowski
    April 11, 2006

    nd-of-life care is already heavily a gov’t service in the US, and is the scariest piece in terms of economics, because there’s no obvious upper limit to the demand for it, or the ability of technology to create new and expensive therapies.

    Someone needs to say: this is what the gov’t will pay for, all the rest you gotta pay for yourselves. Brutal but necessary.

  15. #15 Gareth Wilson
    April 11, 2006

    New Zealand’s public health system has served me pretty well, but I hesitate to recommend anything similar be introduced in the US. The cultures are just too different. For one thing, personal injury lawsuits are not permitted. If your doctor screws up, you get a small weekly cheque from a government agency, not a million dollars from John Edwards.

  16. #16 Jamie Bowden
    April 11, 2006

    People talk about Prilosec and bag the docs for prescribing Nexium, but answer a question for me before you do:

    Does YOUR insurance company cover OTC drugs, even with a prescription?

    I have yet to meet one that does. Once a drug hits OTC status, your insurance company doesn’t want to hear from you about it ever again. I used to get Claritin for $5 for a month’s supply. The OTC availablity is twice the cost for half the pills at a third the strength, and submitting a claim to my insurer would get me nothing more than laughed at.

  17. #17 Dan R.
    April 11, 2006

    Jamie:

    Prilosec is still available via Rx in higher dosage forms — the same as advil or alieve.

    Also, I’ve seen a *few* insurance companies cover OTC’s for very specific items — but a script is still required and its rare.

  18. #18 Jeremy
    December 1, 2006

    you might consider switching pharmacies. At least in my area, most pharmacists will guide a script through the Prior Approval process — making the phone calls, getting the authorization, dealing with the doctor’s office, etc.

  19. #19 Matthew Jones
    December 4, 2006

    The long-serving conservative federal government here has some bee in their bonnet about getting us all onto private insurance, which is proving just soooo popular that the government has to offer a thirty percent rebate on the private health premiums, and still people leave private insurance schemes in droves