Since I am lucky enough to have a job that provides me with health insurance, I made an appointment with an allergy doc in hopes of one day living my day to day life without a handful of tissues.
During that appointment earlier today, I was reminded that
A. There are much more pressing issues than technology that need to be covered, and
B. People think I should be married with kids by now.
Here is how our introductory conversation went;
Me:
"Hi Dr. MacMillian. (reach out my hand to shake hers)
Nice to meet you.Dr.
"Yes, hi. So, are you married?" (nodding her head yes)
Me:
"No."Dr:
"How old are you?"Me:
"30."Dr:
"Have kids?" (she is nodding her head yes, again)
Me:
"No." Dr.
"Okay. (disapproving look)
So, what do you do?"Me:
"I'm a journalist. I write about technology."Dr.
"Ah. For the Journal?" (Another whammy)
Me:
"Um, no, not for the Providence Journal. I write for a technology website; it's all online content. We are based in Massachusetts."
Dr:
"Funny you should mention Massachusetts. Listen to this. I just got off the phone with Blue Cross Blue Shield of Massachusetts (BCBSMA), which, I hardly ever call them because I have more important things to do, but this time I did because I needed to get a new medication approved for one of my patients. So, I call, explain what I need and why, and they keep me on hold for ten minutes. Then they come back and say 'sorry, but our pharmacist doesn't approve that medication. He suggests this other one.'
"The nerve. You mean to tell me that your pharmacist, who doesn't know my patient or what they need, is denying my medication choice? Your pharmacists' decision means more than mine? It is infuriating. I mean, every insurer has their own gimmick, but this is scary. They denied a medication that I know is best for my patient."
Me:
"That is scary."Dr.
"Yes. See, this is why you should forget writing about this technology crap. These kinds of things go on, and someone needs to write about them."Me: Nodding yes.
Dr:
"OK, so what's been bothering you."Me: Um, a lot more than a stuffy nose after that conversation...
Besides the disturbing lack of a bedside manner, I actually enjoyed her spit-fire personality. Plus, she has a point - and I don't mean the point that perhaps I should be married with kids by now, you jerk. I mean her point that health insurers in the U.S. dictate patient care, and the system has got to change.

According to
BCBSMA's website, their "goal is to provide a high-quality, affordable pharmacy benefit without compromising quality of care. Working closely with doctors, pharmacists, and other experts, we manage our program by asking ourselves: How effective is a particular medication? Which other medications are available to treat the same condition? How does the cost of a particular medication compare to that of similar ones that treat the same condition?"
BCBSMA has a
list of medications that have to be pre-authorized before a doctor can prescribe them, as well as a list of
medications that are not covered.
If a doc is granted an exception for a non-covered drug, the patient has to pay the highest level co-payment, and if the request is not approved, patients have to cover the full cost of the prescription.
This, of course, drives doctors and patients nuts. Once recent
Wall Street Journal health blog entry details a situation where health insurers denied access to a medication because of cost, and it received lots of
feedback from commiserating doctors and patients on the related WSJ health forum site.
One
WSJ forum respondent, called Plum Nurse, wrote, "When I left practice as a pulmonary nurse specialist for a job as a nurse epidemiologist in public health, my greatest joy was that I would never again spend hours on hold with insurers or managed care companies fighting to give my patients the care they needed. By the end of my time as the nurse managing a specialty clinic at a tertiary medical center, I spent virtually all my time on the phone. Part of it was for actual clinical care - calling patients - but a VERY large part was trying to convince some high school grad sitting in front of a screen of arbitrary rules that yes, my patient really did need the drug that was prescribed..."
Though unfortunate, health care has become more of a business than ever before. I think this
forum respondent, dubbed Holy Trinity, sums it up nicely:
"Medicine is no longer a noble profession, it is a business. And as other 'noble professions,' especially law and education, have degraded into businesses, it's become all about the provider, rather than the
practitioner."
This is just one of the many problems with America's health insurance system that needs to change.
Our incoming president, Barack Obama, has health insurance on his massive "fix it" list, but who knows if and when any changes in the area of prescription pre-authorization will be made; there are so many other pressing issues to deal with first, like
making health insurance available and affordable for everyone.
I don't see anything in
Obama's plan that would specifically address prescription pre-authorization hurdles, but there are measures that will help patients get medications at lower cost. For example, Obama wants to let consumers import safe drugs from other countries, which often cost much less.
According to the plan, "Pharmaceutical companies should profit when their research and development results in a groundbreaking new drug. But some companies are exploiting Americans by dramatically overcharging U.S. consumers. These companies are selling the exact same drugs in Europe and Canada but charging Americans a 67 percent premium. Barack Obama and Joe Biden will allow Americans to buy their medicines from other developed countries if the drugs are safe and prices are lower outside the U.S."
If approved, this measure would foster an environment of competition between U.S. and non-U.S. pharmaceutical companies, thus lowering the cost of prescription medications for Americans. Presumably, a side effect of lower drug costs would be that health insurers take the now expensive meds off of their "non-authorized" list and cover the cost.
But, maybe I presume too much; I am sure it isn't that simple.
I do know this, though; with
the premiums we pay for health insurance, the medications our doctors prescribe should be covered. Hopefully, one day soon, they will be.