As I write this post, my thoughts wonder if I’m being wooed to the dark side. Rarely (or maybe never) has an insurance company done anything that made my life easier or reduced my workload. A few days ago my medical assistant handed me a denial for a prior authorization (PA) request from a pharmacy. She attempted to do the PA online and was unsuccessful. It was a fairly straightforward diagnosis so it seemed odd that there was an issue getting the drug approved. Our patient has biopsy proven Barrett’s esophagus, a premalignant lesion for which a medication like Nexium is indicated. I sigh and flip through the denial papers to try and understand the reason and am amazed to see the name and phone number of the Humana physician who did the denial. I call her. It’s before 8 AM so I don’t expect an immediate response but a couple hours into the day I am pleasantly surprised (again) to get a return phone call from the physician herself. She tells me that the medication was approved for twice a day use but for some reason the pharmacy requested 90 pills for 30 days. It was only ordered for once a day so that’s an easy thing to fix with the drug store. Meantime I am thrilled. To be able to access a corporate physician quickly and resolve a problem for a patient in record time is a big step in improving patient care and transparency. Kudos to Humana! Don’t stop there please.by
Doctors hate the first of the year. Besides the cold weather, there are a myriad of reasons for that. In private practice one typically goes without a paycheck for two months. That’s a bit of a stressor. Increasingly more frustrating every year is all the changes from pharmacy benefit managers. Finally the physician finds the right combination of antihypertensive drugs, blood pressure is well controlled, life is good! Then the dreaded letter from the pharmacy benefits company arrives, stating that Exforge (or Metoprolol ER or…) is not covered under the patient’s insurance plan. For some reason this year it is extended release medications on seniors’ plans that are not covered, generic no less. The elderly patient, who may be challenged in regard to compliance, now must take his or her medicine two or three times a day instead of just once. No problem, I’m sure the insurance company will send out a nurse to make certain that the patient takes all medications properly. No wait, the nurse is busy sending the patient to the emergency room for a hangnail because she’s worried that pain in the left arm is cardiac. But I digress.
This week a new level of denial has been breached. Now medications are deemed “experimental”. Somehow pharmacy benefit managers have confused off-label with experimental. Why would they do that? Simple: off-label use isn’t excluded on a patient’s insurance but experimental is. In one particular case my patient has a progressive debilitating neurologic disease that is causing pain. The patient already has issues with constipation due to an inability to be mobile so narcotics are not a good option, not to mention that he does not want to be dependent on narcotics for this pain. Amazingly this “experimental” medication was doing a good job of managing the pain for the last year or so.
Not only is the denial of this medication arbitrary and cruel, it is unethical. Off label use of medications is an accepted and necessary treatment choice, particularly with pain, where avoiding narcotics is important for patient quality-of-life and many off-label use of medications is well-studied but not in the drug’s package insert since the medication has long been generic. In the meantime the patient asks ME how to deal with the issue. I recommended that they call their insurance company to begin an appeal process. Frankly a good lawyer might be a good idea as well.by
The Greater Louisville Medical Society (GLMS) hosts an annual “Wear the White Coat” opportunity for leaders in the Louisville community to spend a day with a physician and get a first-hand look at what we do. When GLMS president Dr. James “Pat” Murphy put a direct plea into my inbox it seemed easy to volunteer.
The program began with a breakfast get-together to meet our shadows. Mine was London Roth, an enthusiastic Human Capital Consultant executive with Humana. It took me a while to understand what her job is but both of us are avid social media advocates so it was a match made in heaven. On a Monday morning London joined me for five hours during which most of my patients allowed her to accompany me in the exam room. She listened to their medical issues and participated, with the patient’s permission, when they had questions of her. She was observant, interested and insightful. She was indulgent as I ranted about issues with her company, as well as other payors. She asked lots of questions.
She commented on the awkwardness of our EHR system. She saw first-hand that, even if it is well-intentioned by the insurance company, sending over-worked clinicians patient information of who has not had colonoscopies, mammograms, pap smears, etc. are next to useless. Who in the office has time to work the data, especially if it is not as accurate as the insurance company believes? London also listened to patient stories about how her company’s HR policies affect employees’ ability to care for themselves and their families.
We met again at a dinner organized for the group where each “shadow” related their experience. State politicians spoke about better understanding when legislature affects physicians’ ability to practice. Business leaders talked about how seeing the effects of poor health habits reenforced the need for encouraging their employees to have healthier lifestyles. Community leaders saw how patient support systems (or lack thereof) can determine the success of patient care plans.
Personally, London gave me two gifts: she ended her comments with how well I knew about the little things that were important to my patients, the human connection that makes for a better patient-doctor relationship. And she designed the best iPhone case ever, a gift to me illustrating one of my frequent questions to patients:
Programs like this give IRL* examples of how physicians and patients are affected by the decisions of community leaders and what they can do to impact change in their companies and legislative bodies. As Dr. Murphy said “when you wear the white coat, it becomes part of you forever”.
*IRL = In Real Life a frequent expression used in Social Media. http://www.urbandictionary.com/define.php?term=IRL (caution, this link contains foul language).by
Is anyone else irritated by medical insurance companies’ efforts to improve the health of their members by encouraging them to do recommended tests based on claims-made data? Recently, a patient asked me if he should get the pulmonary function tests his insurance company recommended based on his asthma diagnosis. He does have mild intermittent asthma. He uses a steroid inhaler once a year during the spring for about a month and might use his rescue inhaler with exercise four or five other times during the year. If you check the guidelines put out by the National Asthma Education and Prevention Program it is recommended that a spirometry test or PFTs be performed annually to assess any changes in lung function. The fact is, this patient has been treating his asthma the same way for about fifteen years. He feels fine. So will doing PFTs make a difference? We discussed it (over Christmas and through the patient portal, which I love) and decided that doing testing was unlikely to cause a change in therapy. Since he had better things to do than PFTs he would prefer to skip the tests. Hopefully he won’t see an increase in his premium for refusing to follow his insurance company’s medical advice. Does this make me worry about becoming nothing more than a flunky ordering tests for patients based on Humana or Aetna or Anthem’s “best practices”? In a word, yes.
What irritates me more, is being faxed long lists of patient names with recommendations for mammograms, colonoscopies or diabetic eye exams. Our office is supposed to pull those charts and encourage patients to have their preventive exams. Of course if we do pull them, it turns out the “claims-made” data from the insurance company isn’t all that accurate and many patients have already had their tests done. Thus another waste of the office employees’ time pulling charts. Hopefully it will be easier with electronic records.
When I want medical advice I will talk to my doctor or find an expert on-line, I will not talk to my insurance company. I do not want or need coupons from Humana. Nor do I want my insurance company to remind me of preventive care visits via my telephone. My patients are thrilled by it, however. “Humana pays for me to go to Silver Sneakers! Isn’t that great?” or “A free 30-day Jenny Craig membership is available, what do you think doc?”
Just call me Thomas, because I am a doubter. Nothing is truly free in the insurance business, so somewhere along the line the consumer is paying for the SilverSneaker membership and the salary of the individual who is soliciting companies to provide coupons from the insurance company. Please, just pay my claims and not give me such a headache trying to obtain my prescription from your 90 day pharmacy service. That’s what I would call good service!
|Yes, that her “out” during|
My younger daughter has a condition known as narcolepsy (she OK’d this post by the way). Because of it, she has a tendency to fall asleep any where and any time, but it is worse in the mid-afternoon. During college she was prescribed a medication called Provigil, which improved her ability to function in the real world, particularly in afternoon classes. Her classmates were a little disappointed at how well the medication worked as they could no longer tease her with drooling photographs taken during lectures. Due to the cost of the medication, she quit taking it while doing her present research job in Panama. Recently, she realized that her tendency to fall asleep in the middle of writing was interfering with her ability to finish her research paper. I’d heard that Provigil was now generic so I looked to see how much that would cost us, expecting some improvement in price. Nope it is still $26/pill if you pay without insurance (that is NOT a typo, with a prescription but no insurance coverage, thirty days of the drug will cost in excess of $788). WITH our Humana insurance, it would be a little more than $100/month, IF we could get a Prior Authorization on it. She bought it in Panama for $2 a pill. She did not need a prescription. I suggested that she stock up while she’s down there. Maybe she can get enough to last through graduate school.
Following that personal medication moment, I received a fax from RightSource, the prescription company owned by Humana. They wanted to know if a patient of mine who is taking a blood pressure drug called Bystolic was using insulin. Insulin, as you probably know, is a hormone important in diabetes and can be given in injectable form to diabetics. Bystolic is a type of blood pressure drug that can mask the symptoms of a low blood sugar in diabetics. The weird thing is, this patient is not a diabetic. Humana has yet to answer my request as to why they were asking me the question.
On Friday a patient came to me who is post-menopausal and having some vaginal dryness which is making intercourse uncomfortable. I suggested using a topical estrogen, specifically a drug named Vagifem. Many women prefer this form of topical because it is in a small pill that is much less messy than creams. Now here is where it gets weird. First of all, I could not tell the patient how much this prescription would cost her in the pharmacy because it is a “third tier” listed drug with Humana. She can look it up on line on the MyHumana site but I have no way of knowing. I do know it costs about $68/month if you don’t use insurance to buy it. There are no “generic” estrogen creams BUT Humana lists Premarin estrogen cream as second tier which typically is a $30-40 monthly copay. Here’s the kicker–if you buy Premarin cream without insurance it will cost you $150/tube (a tube will last anywhere from two to four months).
My medication frustrations this week were multi-fold–why do drugs cost so much more in the US than other countries (here’s a link to an interesting article in the New York Times that is old but still rings true regarding this question); why do I have to spend my time answering ludicrous questions for drug coverage companies in order to get my patients’ drugs refilled; and why isn’t there more transparency in medication costs for me and my patients?by