where does the legal drug money go?

Images I was happy to see a health bill care bill passed this past year.  To me, it meant a change in a different direction that was sorely needed.  One bill isn't going to fix the system but at least it is a step towards a new path. 

Personally, we have been lucky in terms of our health.  We all show up for our annual check-ups and bi-yearly dentist appointments with few hiccups.  There has been conversation that we are going to change our health care policy this year to a health care savings account but have yet to pull the trigger.  Regardless, I do use our insurance card for any prescribed drugs we pick up at the pharmacy.  This week I got a small glimpse into the insanity of the health care system. 

Emily takes a particular medication for her skin.  It is prescribed by our dermatologist.  Each time Emily runs out, we repeat the process.  The doctor calls in her prescription to the pharmacy, the pharmacy calls our insurance company (who is Oxford Select) and then they decide not to give Emily the drug.  Then our doctor (her assistant) calls Oxford and goes through the explanation on why they prescribe this drug to Emily. Oxford then gives it the okay by giving the pharmacy a number which allows them to pass on the Oxford savings to us.  The prescription then costs us about $40 and lasts for roughly a month.  Lots of back and forth every single month which is a cost that is not equated into the transaction. 

Last week we went to fill the prescription and the 3-4 day process began again.  By the time Emily got out to the beach, they had not finished the monthly game of tag.  She came without her meds and not that it is life threatening but she needed them. 

I called our dermatologist and asked them to call in another prescription out here.  They did.  I figured that I would just bag the insurance out here because it is always such a hassle and her drugs have already been filled in the city.  Thinking it couldn't cost more than $80 and I'd only do it once without insurance.  I assumed that there is no way that the insurance company would agree to two separate prescriptions for the same 30 days when they make it so difficult just to get the one.  I assumed right. 

I walk into the pharmacy and ask to pick up the meds for Emily Wilson.  She pulls the bag out from the back and that was when I noticed the price.  $567.  At first I thought it must be a typo.  She looks at me and asks me if I have an insurance card.  Standing there speechless, she is just smiling and nodding because she is well aware of the difference.  I tell her I am going to come back with the card.  I am blown away by the cost.

Back with my card, they go through the process of calling in the prescription to the insurance company and the prescription is declined.  The pharmacists calls the NYC pharmacy to try and switch the insurance to here but ends up the prescription had already been picked up by someone in our house.  I told the pharmacist that I was blown away by the price.  I had no idea.  He said two things that stuck.  One is that he isn't making the money on the difference in price (someone is) and two is that this particular drug doesn't have a generic brand.

I understand the high cost of research and development on the pharmaceutical companies part and they are charging high prices to recoup that.  I understand that the insurance company makes a guess of how many people under their umbrella are going to buy the drug Emily uses every year and negotiates a price with the pharmaceutical company based on that.  Hence that is why we pay only $40 with the insurance card.  Yet do they really believe that holding back for four days and making it so difficult to get the drug is the best way to reign in their costs? 

The system is surely broke.  We spend billions of dollars on health-care from hospitals to medications.  We now have the ability to help people live longer and healthier lives yet the actual costs are so high.  The pharmacist isn't making anymore money.  The companies are making more money which in turn pays for lobbyists to keep the whole circle going. 

I certainly don't know the answer on how to fix the system but my tiny observation over the weekend in dealing with the insurance company to get Emily a skin drug which is just a benefit not life saving blew me away.  $566 for 30 pills vs $40 with my card.  All I can say is, wow.