There is no question that the system we have is broken. Not only is the price of Health care through the roof, the decisions made by insurance companies on what and if they want to fund a particular treatment is insane.
Today I called our doctor to please call the pharmacy to re-up a prescription for Emily. When
I got to the pharmacy they informed me that the new dosage, which is a tad higher, had to be signed off on by our insurance company.
So even though Ems doctor believes she should be using a higher dosage of a particular medication, our doctors assistant had to call Oxford and ask them if that was ok. Then
Oxford had to fax the doctor a form to fill out telling them why she prescribed this dosage and then of course fax it back. Then someone at Oxford (probably not a medical person) has to give it the ok and fax it back. Then the doctors office has to call the pharmacy and give them the confirmation number that has been issued from Oxford.
Total amount of hours, time and energy over one persons prescription is equal to how many dollars? Does this make sense? There has to be a more efficient, time saving, less costly way to keep Americans healthy.
The system is broken and the fix might not be perfect and it will take time to tweak but it has to be better than this. Meanwhile, I am still waiting for the sign off.
Comments (Archived):
This is a perfect illustration of the need for an electronic records and request standards. The SEC requires larger companies to file electronically, most of us deal with chain drug stores as well as large insurance companies. They should link all of these things together for an easy 1 click Amazon approval solution.While this prescription could be inexpensive, there are some expensive drugs that might be worth their while to double check.Imagine if all of our health care data was online? We could spawn companies like Mint to login and figure out where to save money, find better treatments.
That would be amazing if everything was electronic. If only all of ourhealth records were online for easy access to the next doctor. I am goingto hope that in time this will all happen.
I’m of the opinion that the first thing Obama should focus on is efficiency.The social engineering piece can come second and will probably be easier ifwe can show a win on things like this.
Totally agreed. Unfortunately Government is the farther thing fromefficient.
This fault is not electronic records vs. telephone calls. The problem is the pharmacy benefit management company hired by your insurance company. They want to make it as difficult as possible to give your daughter that particular drug because it might cost more than half a cent per pill. At one time you did not need pre-approaval for any regular medication, but now since even a non-profit is in business to make as much money as possible, they hire for profit companies like express scripts to tell you what you can and cannot have depending on how it will affect their profit margin as the pharmacy benefit management companies are for profit companies. Express scripts, a pharmacy benefit management company, is on the nasd board with stockholders. If one didn’t know better you could argue that if someone is managing my benefits than my premium should be lower? NOT TRUE. Express Scripts, for instance has made so much profit that they have bought up WELLPOINT’S pharmacy benefit management company and others. In 2003 Express Scripts was hired by Empire Blue in New York to manage their prescriptions. The rote was that it would save money for Empire Blue. Instead any money express scripts might have saved by switching people to generics Express Scripts kept the savings and billed empire blue as administrative costs. The attorney general at the time got wind of this and sued Express Scripts for fraud for 100 million. Express Scripts settled and paid 27 million. Express Scripts has done this in other states as well. Losing 27 million is peanuts for them and they have not missed a beat. Physicians are now asked to write as many generics as possible and will get bonuses from insurance companies if they switch a patient over from a brand name drug. Physicians can also be penalized for writing too many brand name drugs as well as they will get reviewed by the insurance pharmacy benefit manager. Do you realize there is more profit for the pharmacy in a generic than in brand name drug?The easy answer is pay out of pocket for the prescription and don’t bother going through the insurance company. You ask why do we have insurance? Good question. Mine is now going up to $1485 a month for an individual policy.Instead of everyone suggesting limits on patient care which means limiting brand name prescriptions why the heck doesn’t someone suggest that maybe some of the companies that profit from these businesses make a bit less. If doctors get a lump sum to treat you for a year you will get even worse servicesas it is coming out of their bottom line. You know you can pay full price and get a toyota corolla or you can get a mercedes with a discount and the price would be the same, Everyone blames patient usage but there is so much profit in these companies that they could really give more and charge a bit less.As I went on a ppo I became at the mercy of express scripts so I bought a walgreens pharmacy card and don’t bother with the insurance for most routine prescritions as it cost me more with the co-pay and pill limits using my insurancepolicy and you ask what $1485 month buys in premiums ? Vitually nothing.This is from a state with universal health care.
I recommend to you and your readers Stanley Feld M.D’s blog “Repairing The Healthcare System” which he has been writing for some time. Stanley is a retired Endocrinologist who was in private practice for 30 years. He is beholden to no one and calls it like it is. On his blog site there are summaries of past blogs and links to all of them. Cecelia Feld (Stanley’s wife)
How much did it cost the physicians office to fill this prescription? How much do you think he got paid? (zero) How much do you think it cost the Oxford? How much do you think they will charge you on your next premium (about 3 times the cost). This is call overhead for Oxford/Unitedhealthcare.The government plans pay the same overhead.
That’s unfortunate.
We all laugh about the “death panels” but what is really meant is Medicare and the insurance companies have decided not to treat terminal illnesses aggressively for our over 65 elders. My girlfriend’s mom was on medicare and after a diagnose of stomach cancer it was decided by the insurance company MEDICARE not to allow her to have aggressive treatment for her cancer even though she wanted it. They denied her admittance to mass General for treatment. That was 5 yrs ago. Of course she is dead now.My sister has a brain tumor. She had decided to not aggressively treat it meaning no surgery or radiation. It is an endocrine tumor. Slow growing .She decided to live life rather than spend years in the doctor’s office. She had been a subscriber with Blue Cross and had religiously paid her premiums for 68 yrs. No medicare but when she hit 65 a policy that cost her $ 1385 from Blue Cross. suddenly she loses strength in her lower body because the tumor is making too much cortisol in her body and is making her almost paralyzed. This is her first hospitalization and treatment for the tumor that she now has had for 17 years and the hospitalist says no hope. Let’s give her morphine so she can die. . I say she is not even in pain. To me the hospitalist is part of some weird “death panel” speaking for the insurance company to cut her one chance at having some more life. The pallative care doctor says she should get aggressive treatment if that is her choice. She can be saved. Now I start a battle with the hospitalist to treat her. All the years of my sister saving the system meant nothing. Now when she needs help I spent my sister’s one hospitalization battling the doctor who wanted to kill her. How is the hospitalist benefiting from my sister’s death and why isn’t my sister allowed to use some of those built up premium dollars she never used with blue Cross.to now save her life?Believe me Joanne wait til your Mom gets sick. If you think having to get a brand name prescription approved is crazy wait until Mom may need an x-ray and medicare or her health insurance deems that she has to be reviewed by American Imaging Group, the company that is the imaging benefits management group who will decide how allowing your mom an x ray might affect their bottom line. If Mom thinks she might have a gallstone and it does not show up on a doppler. The next step should be a cat scan but that cost more money and your doctor might have to get a pre-approval. If he has the time maybe he will do it but if not he says oh! the ultrasound shows nothing probably just a constant bad bellyache when it could be a stone hiding. When you mom is doubled over with unbearable pain then maybe someone will do something but if there is tort reform and nothing will happen if the physician doesn’t and if the doctor loses money by ordering that cat scan why should he even bother. He will lose income and it takes paperwork for pre-approvals and what the heck he won’t get sued if she dies from a infected gallbladder.because he didn’t order the cat scan.We might all get insurance but certainly not any good health care..
Holy crap, Ellen’s insights and first-hand reports are scaring the hell out of me. This is unreal… I used to live in Massachusetts myself, had coverage via my husband’s job – it was fine, but we never had real emergencies/ critical illnesses, and I only noticed toward the end, before we moved away, that something funny was starting with getting prescriptions filled with the brand medicine, and not the generic. It sounds like things have gone from iffy to impossible in the 7 years since we left.I wouldn’t mind moving back to the US, but reading all this (and seeing the hysteria around Obama’s attempts to reform health care), I think I might want to stay in Canada. Honestly, it’s not bad, our single-payer system here. (I say “our” since I’m a dual US-Canadian citizen, so I have a foot – or heart chamber? – in both countries.)Joanne, the thing that really struck me about your story about Emily’s prescription is just how many eyeballs actually get to view your daughter’s medical record, or at least the request for a higher dosage of whatever medication it is. You don’t want to say what the medication is, because you respect Emily’s privacy. But since you blog – and your daughter does, too – and you both participate in social media (“we all live in public,” etc.), you have to wonder how long it’ll be before some peon at one of the many many levels of insurance bureaucracy googles names and starts hoarding (and possibly disseminating) interesting tidbits that should be private.I’m not expressing this very well … What I mean is: everyone has a right to live in public, to blog, to participate in social media. Everyone also has a right to privacy. But with the byzantine complexity of health insurance (all the hoops you have to jump through), there’s a real danger of unwanted and unwarranted privacy breaches because private information is being exposed to too many people (unnecessarily). I find that disturbing.
Both of you make not only good points but Ellen’s first hand knowledge ofthe system is truly frightening. The system is obviously seriously flawed.I am not that intimately familiar with the changes that Obama is looking tomake but there has to be some movement forward to provide health care foreverybody starting with an annual check-up. My guess, like all changes inthe system, is that eventually there will be a variety of lawsuits that gothrough the system over the new health care bill and through those rulings,there will be changes that will hopefully be better for all Americans. Whatwe have now just doesn’t work and the people who show up at the emergencyroom without any insurance costs all of us dearly.
Right now I am going to invest in Express Scripts, American Imaging Management, Health Intergrated Systems Physicians Health Care Services where computer programs tell you how long a patient stays in a hospital or if that test is necessary and other benefit management for profit companies because after the Obama health care plan these are the companies that will make huge dollars. Add in some hospice companies like Amedisys. because their nurses will be the ones taking care of people at home if they are not cut out totally because of their cost. Our premiums go to health care managers and their ceo’s to deny us any good continuous care.A yearly physical is all well and good but when you get that life threatening phantom pain it is a good diagnostician with all the tools of his trade to figure out what is wrong. In the long run this is the cheapest for society because then you will get a fully functioning self sufficient adult.