As taken from the KHN article, Bram describes the beginnings of his dilemma of getting Insulin:
“I’d been waiting since September for an appointment with an endocrinologist in St. Louis; the doctor’s office couldn’t get me in until Dec. 23 and wouldn’t handle my prescriptions before then. When I finally called a pharmacy to sort this out, a pharmacist in St. Louis said my new employer-provided insurance wouldn’t cover insulin without something called a prior authorization. I’ve (Bram) written about these, too. They’re essentially requirements that a physician get approval from an insurance company before prescribing a treatment.”
My (run) healthcare records follow me across the nation. A new pharmacy or doctor can get to my records and sort out rather quickly what is going on with me. Some of the coding of my issues in my record, I have disputed. It benefits you to look at this on occasion before you get a med you do not really need. For example, how can I have a Cholesterol issue when it is at 104? You can’t, as it is something else. A coding issue to upcharge. This is off topic from the issue I have discussed with Kip Sullivan.
Insurance company bureaucracy and paperwork is a cost issue and also a health issue. The latter of which can threaten a patient’s life.
“Since September I (Bram) was waiting for an appointment with an endocrinologist in St. Louis. The doctor’s office couldn’t get me in until Dec. 23 and would not handle my prescriptions before then.”
Not sure why a doctor could not authorize additional meds based upon previous diagnosis as specified on his health records. There is more to it than just this. The important part of the repeated initial sentences is the last sentence
“When I finally called a pharmacy to sort this out, a pharmacist in St. Louis said my new employer-provided insurance wouldn’t cover insulin without something called a prior authorization. I’ve written about these, too. They’re essentially requirements that a physician get approval from an insurance company before prescribing a treatment.”1
Bram’s Meds are low, prescription is at the pharmacy, and insurance company sends a message to pharmacy about “waiting for a completed prior authorization form from the new physician.” This is typical of insurance companies requiring a “faxed paper” version of an authorization for a med. Verbal conversation or email is not good enough. It has to be paper faxed over.
The American Medical Association has a website outlining proposed changes to the practice, while the insurance industry defends it as protecting patient safety and saving money. It feels like a lot of paper work to confirm something we already know: Without insulin, I will die.
Single Payer expert Kip Sullivan was interviewed on the Ralph Nader’s Radio Hour. Kip made the comment to Ralph Nader about 34%1 of all healthcare cost being attributed to administration expense. I asked Kip for the breakdown1 as all I have ever heard was a 20% administrative cost.
If you have not heard this Radio Hour, it is worth the listen as it focuses on Medicare versus Medicare Advantage.
After spending 45 minutes on hold the next morning, I finally got through to the pharmacist, who said my insurer was still waiting for a completed prior authorization form from my physician. I called the doctor’s office to give it a nudge.
Seven days of Meds left.
But late in an afternoon, I got an automated message from the pharmacy about an insurance issue.
After spending 45 minutes on hold the next morning, I finally got through to the pharmacist, who said my insurer was still waiting for a completed prior authorization form from my physician. I called the doctor’s office to give a nudge.
Four days left. 2
I called the pharmacy again on Thursday at 7:30 p.m., figuring it’d be less busy. I got right through to the pharmacist, who told me my insurer was still waiting on the prior authorization form. Friday morning, the diabetes nurse at my doctor’s office said she’d check on it and call me back.
I’d be out of insulin the next day.
Live Tweeting Now . . .
My attempt to refill my prescription and started to get the kind of messages that are familiar to anyone in what’s known as the “diabetes online community.” People in Missouri offered me their surplus insulin. Some suggested I go to Walmart for $25 insulin, an older type I have no idea how to safely use.3
I was ready to try the option of using a Insulin manufacturer’s program4
Before the attempt. I heard back from the nurse who had called the pharmacy (she had spent 25 minutes on hold) and learned that my new insurance wouldn’t cover the brand of insulin I was using. The pharmacist was checking on a different brand.
The insurance approvals a different brand
The pharmacist called: My insurance would cover the other brand. But the pharmacy might not have enough to fill my order. She said I should call a different branch of the chain.
12 hours’ worth of insulin left
The first location I called was also out but pointed me to another one having it.
I got it. It took 17 days and 20 phone calls.
The time wasted by me, the pharmacists, the nurses and probably some insurance functionaries is astounding and likely both a cause and a symptom of the high cost of medical care. The problem is also much bigger.
On Dec. 23, I finally saw my new doctor, who sent in a new prescription. That night, I got a message that my insurer was waiting on a prior authorization.
I have 17 days’ worth of insulin left.
I have been fortunate and not had the experiences Bram endured. Adding to this post your experiences would be enlightening. Please do . . .
1 Kip in an email to me: “‘US insurers and providers spent $812 billion on administration [in 2017] … (34.2 percent of national health expenditures) versus … 17.0 percent in Canada.’ (David U. Himmelstein et al., ‘Healthcare administrative costs in the United States and Canada, 2017,’ Annals of Internal Medicine, January 21, 2020.)”
2 The price of my prescription without insurance was $339 per vial of insulin, and I use about two vials per month. Normally, I pay a $25 copay. Without the prior authorization, though, I’m exposed to the list price of insulin, as is anyone with diabetes who lacks insurance, even if they live in one of the states with copay caps intended to rein in costs.
3 My new strategy was to use one of the programs that insulin manufacturers started recently to help people get cheaper insulin. The very same day, the U.S. House Committee on Oversight and Reform’s Democrats released a report deriding these types of assistance programs as “tools to garner positive public relations, increase sales, and raise revenue.”
4 Insulin, etc. Programs; Lilly, Sanofi, Novo, Medicaid, Medicare