Health insurers dodge expensive medications, care

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.

Sweet spots of 2009; stocks, fuel, the economy...it ain't all bad

Last year really sucked; gas prices spun out of control, formerly rock steady businesses collapsed, people were swindled out of their last cent by criminals in expensive suits, and unemployment rates hit staggering highs.

And while many people are still reeling from all of this, there are glimmers of hope ahead; 2008 is behind us (good riddance) and we only have about 90 more hours of a Bush presidency (good riddance). I'm not exactly jumping for joy right now, but there is a light at the end of the tunnel.

So, in the words of Stuart Smalley (now Senator Al Franken), I'm going to do a terrific blog today! And I'm gonna help people!

1. Up until 2008, generations X and Y only knew a wealthy America; we now know what rock bottom looks like, and there is only one place to go from here. Maybe on the way back up, we will all appreciate the things we have a little bit more. After all, you need the bitter to appreciate the sweet.

2. We now know that if you are in commercial airliner like, oh, say, U.S. Air flight 1549, and the engine fails, death is not necessarily imminent. I never worry about dying during air travel anyway, but from now on I might pay a bit more attention to the flight attendants' safety tips instead of quietly telling him or her to shut the hell up so I can read my book in peace.

3. Many stock prices have fallen so dramatically that those of us who couldn't afford to invest when times were good (i.e. people who shop at T.J. Maxx because paying full price for anything is just plain foolish) can buy stocks at bargain basement prices now.

4. U.S. fixed interest mortgage rates hit a record low of 4.96 percent , so if you were raped by subprime lenders a few years back and are fortunate enough to still have your home, you may be able to refinance, save a bit and afford food once again.

5. We are officially moving out from under the Bush reign of terror. Did I mention we only have to call him Mr. President for another 90 some odd hours?

6. Obama.

I'm sure there are plenty more diamonds in the rough, but that's all I've got for now. Let me know what I've missed.

Buffy the inbred cocker spaniel; a cautionary tale

From the ages of about nine through 13, my Christmas list consisted of one thing; a cocker spaniel puppy. In the weeks leading up to Christmas I would daydream about waking up on Christmas morning (at 4 a.m., when my parents were still sleeping off their hangovers from our annual Chistmas eve party), running down the very short hallway from my bedroom to the living room and finding a tiny blonde cocker spaniel puppy with a big red ribbon sitting quietly under the tree.

I imagined her jumping all over me, laying puppy kisses on my face and playing for hours.

Of course, my daydreams never included the parts where I had to clean up the puppy crap and piss from the carpets while we trained her, or taking her outside to do her duty at 6:30 a.m. in 30 degree January weather. Nor did I imagine this adorable pure-bred cocker, with her curly haired
ears and her white, freckled muzzle, to be an inbred schizophrenic that would viciously attack me, my brothers and my parents at least a 300 times throughout her 16 years of life for offenses like reaching towards her food bowl, taking away things she should not be eating or simply coming near to pet her when the ornery bitch didn't feel like being bothered with us. And never did I imagine this 30 pound dog being so frightening to others that we would have to lock her in a bedroom when company came over to prevent any Cujo style attacks on innocent women and children. How could a creature so small and soft and cuddly be so evil?

Because we didn't want to believe our doggie was simply an asshole, we hypothesized that Buffy (shut up, it was the 1980's) was mentally disturbed due to inbreeding. We met Buffy's mama, but we didn't meet the papa, who could have been a son or brother of father. Being 13, I didn't think of that, and clearly it didn't cross my parents minds either.

Sure, there were plenty of good times with Sybil; some of her personalities were quite sweet, and we loved her despite her shortcomings. But, had we done our due diligence before investing in a pet, we could have avoided the traumas we endured.

Now, I'm not discouraging people from getting a dog. I am a dog lover, and encourage anyone who has the time, energy and love to devote to a dog to get one. But there is a right way and a wrong way to go about it.

I'm sure a lot of kids (and adults) are begging for a puppy right about now - current movies like Beverly Hills Chihuahua and Marley & Me ensure that. If you plan to give in, learn from my mistake and make sure you get your pup from a reputable breeder, or better yet, rescue a dog from a shelter.

Beware of pet shops like PetLand use puppy mills, where female dogs live their entire lives in cages and exist only to to pump out puppies. The breeding is substandard, with unhealthy mothers being partnered (a.k.a. raped) by their own brothers, fathers and sons to pump out puppies. The poor conditions of puppy mills also lead to ill pups. In other words, don't support pet shops that use puppy mills by buying dogs from them. Use your local shelters or ask the pet store owner to show you documentation of where the pups come from before buying. They should be able to provide it.

The American Society for the Prevention of Cruelty to Animals (ASPCA)has plenty of resources on puppy mill scams, laws protecting consumers and ways to find a puppy or adult dog.

By doing our homework, Robbi and I have the perfect dog, Bella, a bullmastiff. We bought books on the breed before deciding on her, and ended up adopting her from a local guy who introduced us to both her parents. Bella came from the mother (Cocoa)'s second and final litter, and it was clear the breeder loved his dogs. In fact, it was hard for him to let the puppies go when the time came, and he told us to bring Bella back for a visit anytime.

We felt really good about where she came from, and the good breeding is quite obvious in her demeanor, health, and her ability to be endlessly sweet. She lights up our lives every day.

Thankful to be thankful on Thanksgiving

It occurred to me a little while ago that I have been thinking about the upcoming Thanksgiving holiday the wrong way.

I've been complaining to myself that Rob and I have to hop between relatives houses on Thursday and won't be able to relax, but that isn't really something to complain about. God, what a jerk I am. We have places to go where there will be food, heat and family surrounding us (even if some of them drive us crazy). This is something many Americans do not have the luxury of complaining about this year.

I recently wrote an article for the Providence Business News about how the economy is affecting non-profit organizations like Crossroads Rhode Island, the state's main homeless and womens shelter. The state legislature cut funding for many state-based social services, so nonprofit groups are expected to fill the gap, but the state also cut funding for nonprofits, so these organizations can not afford to do so.

Crossroads is supporting thousands more people this year than previous years, many of them experiencing homelessness for the first time, and many of those people will converge at the shelter on Thursday for a hot meal. But homeless shelters like Crossroads can only provide food and housing if people support the cause, and it is easy to do. On Crossroads' website is a place to give the down and out among us something to look forward to this holiday season, including things like a few hours of GED tutoring, a Child's Winter Clothing Kit or Healthy Meals for 2 Families for a month.

Shelters in every state are in the same situation and need support. Give a few dollars this year and let someone else have something to be thankful for. Whatever you give will come back to you tenfold, even if it is only within yourself.

Americans vote for change, end cruelty

Like the majority of Americans, I let out a sigh of relief last night when our votes to change the way things have been for the past eight years were heard; Barack Obama will be the next U.S. President.

The U.S.'s first black president elect won 349 electoral votes - double the number of votes his opponent Sen. John McCain received and 79 more than the 270 electoral votes he needed to be voted president.



If his good democratic and economic policies, his stance of increasing renewable energy and decreasing our dependence on foreign oil, his desire to end the war in Iraq responsibly, his understanding of womens issues and his overall BluePrint for Change aren't enough, Obama also offers us a way to mend tattered foreign relations.

Most countries were pleasantly surprised that Obama was voted in, especially after their disappointment with last election, when Bush was re-elected somehow. Hopefully, having Obama at the helm will put the U.S. back in good graces with our partners in the United Nations and heal the wounds Bush caused over the past eight years.

The French newspaper Liberation reported "In this election, a French bias about Americans is swept away. Every four years, we complain about the poor voter turnout in the USA -- which is a reality. But this year, given the election's historical significance and thanks to the technological advances of the Internet, we saw an exemplary mobilization of American voters..."

"We also need to change our preconceptions about American prejudice. For the first time, an African-American and a woman were candidates for the highest office in the land. It seems like America could teach us a thing or two about democracy," the Liberation reported.

I'm also thrilled that voters chose to end inhumane treatment of animals in Massachusetts and California during this election. The Humane Society of the United States reports that California approved a ballot measure to halt the inhumane confinement of animals on factory farms, and voters in Massachusetts approved a measure to ban greyhound racing, because when these dogs aren't being exploited for gambling, they are locked up in tiny cages.



These are small steps in what will be a marathon of legislative changes for animals, but important ones in our evolution as a society; people don't need to show their superiority over animals by treating them with disrespect. Farm animals are vulnerable creatures that depend on us for care, and if we intend to take their lives for food, they deserve to be treated respectfully for it, and given a good life until it is taken.

Dogs offer us their loyalty, love and protection, and we should return the favor by treating them, and all animals, with some dignity and respect.

Historical high jobless rates deplete state unemployment funds

There are so many people applying for unemployment benefits that callers often can’t get through, and even if they can, unemployment checks may not be available, according to a new Stateline.org report.

In North Carolina, where more people are out of jobs than ever, state employees are working overtime and on weekends to reduce a backlog of requests to verify unemployment benefits that has been as high as 17,000, compared to only a few cases a day a year ago. And in Michigan, which has the highest unemployment rate in the country at 8.9 percent, there isn’t enough money in its unemployment insurance fund to cover claims, so the state has been forced to borrow from the federal government to pay jobless benefits, Stateline reported.

The number of Americans filing new claims for unemployment benefits is at the highest levels since the Sept. 11, 2001 attacks. Weekly claims have exceeded 400,000 for 11 weeks, compared to 324,000 a year ago, a level that economists say indicates a recession, according to Stateline.

For example, I know someone who works in the construction industry, which has slow periods and seasonal layoffs, and this year has been especially slow. He recently had to file an unemployment claim for a couple of weeks, and dialed the number to the Rhode Island unemployment office - where unemployment is over 8% - and the line was busy for at least 25 minutes before it rang. The wait to talk to a person was well over an hour.

Also, I just spoke to Anne Nolan, the president of Crossroads RI, a homeless and womens' shelter. The non-profit organization was allotted $500,000 in state aid two years ago, but for the past two years has only gotten $200,000 in aid. In addition, she is worried that donations will slow down due to the economy.

"When people can't afford to pay for their own heat, they can't afford to donate to us," Nolan said. "Crossroads has been through tough times before, but this feels ominous. We are dealing with state cuts and at the same time, getting more people who are experiencing homelessness for the first time because they can not support themselves."

And if unemployment funds dry up, there will be even more people knocking on the doors of shelters like Crossroads.

The issue with unemployment funding is that states typically collect payroll taxes from employers to pay for jobless claims; lawmakers set the tax rates, the maximum amount of the unemployment checks and the duration of benefits. Many states have had to increase unemployment payments but have not increased payroll taxes to keep pace with the payments.


So far, unemployment insurance trust funds are in danger in California, Michigan, Missouri, New York, Ohio, South Carolina and Wisconsin, according to the National Employment Law Project, a policy group based in New York that advocates on behalf of the unemployed. That group reports 11 additional states are having trouble doling out jobless benefits.

Until economic confidence returns and banks make it easier for businesses, governments and consumers to borrow money to meet payrolls, pay bills and buy houses, companies will continue laying off workers. Major institutions like Bank of America saw steep revenue declines this week and some analysts say a number of banks won't make it through the current credit crisis, even with the ridiculous $700 billion federal bailout plan.

Subprime mortgage fun equals worst hangover ever

Reading about all of the financial messiness on Wall Street these past few weeks brings back fond memories of better times, when subprime mortgage bankers made billions of dollars on the backs of hopeful home buyers who couldn't actually afford the 100% mortgages they were getting.

For a small window of time, I was part of the fun.

After I graduated from Northeastern University in 2002, I scored my first full time reporting gig at the Sentinel and Enterprise in Fitchburg, MA (a.k.a the armpit of the Commonwealth) earning a fat $18,000 a year. The editor worked us lowly reporters to the bone for peanuts every day, so after about a year I moved to a newspaper in Providence for an increase in salary - about $30,000/yr. Of course, supporting myself and paying back $40,000 in student loans on that salary still didn't cut it, so I moved to the dark side; I became an account manager for a subprime lender called SouthStar Funding.

My friend Stace already worked for them as a sales rep, and her boss was recruiting big time so they gave this inexperienced gal an interview. Actually, it wasn't a real interview; Stace and I met SouthStar's Northeast Regional Sales Manager at a bar in Providence called the Hot Club for drinks, and he hired me pretty much on the spot.

He said I would make about $80,000 a year as an account manager. That was about a $50,000 pay increase, so it was a no brainer for me.

Looking back, I shouldn't have taken a job from someone who interviewed me at a bar, especially from someone who proceeded to get drunk. And the fact that he tried to convince us to go to some local strip clubs with him should have been another red flag, but I was young and broke and blinded by dollar signs, so I ignored the glaring lack of professionalism. (We didn't go, by the way).

My first real day on the job I took a call from a mortgage broker whose loan was tied up in underwriting. She wanted to close a loan that day and was screaming and swearing at me over the phone. I told her "it isn't wise to scream at someone who can help you," and she eventually calmed down. The other girls in the office commended me for handling her so well and said I would do great there, since dealing with screaming brokers was a big part of the job. It served as a glimpse into what I would deal with just about every day.

Besides that hell, working at SouthStar, and most mortgage companies from what I heard, was a big party because most people were making tons of money. There was even a refrigerator in our Connecticut office full of beer, and many days I could hear the regional sales manager cracking the first one open at about noon. There was also a beer fridge in the Ohio offices where I trained for the job. I thought this is crazy, but what a cool place to work.

I quickly realized that the brokers and most of our sales reps were motivated by money and had no regard for whether or not their clients could actually afford their homes once they got them. They let greed guide their decisions.

I would imagine most of them had to were ski masks to their closings, because they were robbing home owners blind. Most brokers wanted to add two to three points (1 point is 1% percent of the total loan). SouthStar only allowed brokers to add up to two points on the back of a first loan, and some brokers didn't work with us because of that. Other companies let brokers add points on the front of a loan and on the back, so they could charge four points on a $400,000 loan and earn $16,000 on it.

Most of the loans I had to pre-approve were from people with credit scores of 620 or below. If they had a 620 score - which means they had lots of delinquent accounts on their credit report - they could "state" their income and get a 100% loan in the shape of an 80% first mortgage and a 20% second. Of course, with a low credit score their interest rates would be sky high - maybe 9% on the first and 14% on the second loan.

So a potential homebuyer could 'state' that their income as a convenience store clerk was $75,000 a year, and as long as that salary was within 15% of the earnings listed on a site like Salary.com, we would accept it. Often times, the mortgage brokers would coach the home owner and tell them to state their income as a "manager" instead of a clerk to get away with more income, but our underwriters would find out and the loan wouldn't get through. The 'cool' underwriters would throw that false employment information away and let the mortgage broker come back with something more reasonable.

So, say a Wal Mart cashier wanted to buy a $275,000 home, and their credit score was 640. The broker would state their income higher than the $22,000 Salary.com listing, and then add someone else to the loan who would supposedly be living in the home with them, so that person's income could be counted as well.

Of course, our underwriters knew these tricks and killed a lot of loans, but they also let plenty of them slip through.

SouthStar allowed people to break a 100% loan into two parts so a buyer could get 100% financing and avoid having to pay Mortgage Insurance, which was required on loans over 80%. So on a $200,000 first loan and a $75,000 second loan the interest rate might be 8% and 13% respectively, which equals $1,467.53 a month on the first mortgage, and $ 829.65 a month on the second.

With a 640 credit score they also had the option of paying interest only for up to ten years. Many people used this "perk" because they couldn't actually afford the home they bought at the income they really brought home.

Brokers would tell the home buyers to refinance when their interest only period kicked in to avoid paying the full payment if they had to.

These 100% mortgages were popular because it gave people who couldn't afford a home access to the American dream. Unfortunately, the subprime lenders giving them these loans didn't give a damn that the dream was built on quick sand.

After a year and a half at SouthStar, I couldn't stand being there anymore. Besides the fact that I hated doing mortgages and dealing with angry brokers everyday, I wasn't making what I expected. I was an account manager for the top sales team in the region, and I barely made $50,000 a year - about $30,000 less than I was told.

About three months later in April 2007, SouthStar Funding closed down along with a number of other lenders because investors stopped buying pools of crappy loans they were selling. I got out just in time.

A year later the subprime mortgage collapse has hit banks we thought were bullet proof, like has Fannie Mae, Freddie Mac, and Lehman Brothers.

Now the government is asking us to forgive the greed of subprime lenders and bail them out with $700 billion of taxpayer money. What about the people who were given a mortgage they couldn't afford? Are we bailing them out as well? No.

The bailout plan didn't pass yesterday, and the Dow Jones plunged a record 777.68 points, losing $1.2 trillion dollars.

One of the main reasons the plan wasn't passed is because we don't know if it is a good idea; many analysts say it isn't. President Bush says it is imperative for us to pass the bailout plan quickly, but he also said there were weapons of mass destruction in Iraq and sent us to war there. Fool us once, shame on you, fool us twice, shame on us.

Generally, the American people don't want to bail out private companies. If there is a bailout plan, it needs to be in the form of a loan that us tax payers will make a large return on investment (ROI) with, the same way these mortgage lenders made interest on the backs of people who couldn't afford the loans they were approved for.

Former President Bill Clinton was on The Daily Show last week and he made some good points about the plan. A strong ROI on the $700 billion bailout was one of them. He also said there should be a moratorium on foreclosures; those loans should be reviewed and re-written to avoid foreclosures. This would be less expensive to America than a foreclosure. Makes sense.

The bottom line here is that our economy is in a lot of trouble because of the mortgage industry was drunk. Now it is time to pay the piper, and they want detox help from the taxpayers. I'm not buying it.