The Real Evil

If you're unhappy with healthcare in America, well, first of all just be happy to be healthy.  Second of all, direct your anger at the right places.  I'm not saying I know exactly what goes on everywhere, but holy shit there is stuff going down that is regoddamndiculous.

This will be a meander away from me trying to be funny and just be me being really upset.  But do carry on, I beg you.

Among many other duties at my job, I get medications approved for patients.  That process alone, beyond just being frustrating and near impossible, is mind boggling when you really sit down and think about it.  So, here's how that "works."  You have insurance.  You pay for that in some form or another.  That insurance only covers so much of whatever you get.  That insurance will also probably have some kind of prescription coverage with it.  The insurance company then sets up a formulary--the drugs it deems appropriate for you, because, you know, they know you, your medical history, and are your doctor or at least think they are.  If you need one of those prescriptions, you get it discounted.

But if your doctor, God forbid, prescribes something off formulary you have two choices: pay full price or your doctor has to attempt to get an authorization for that medication.  That is where I come in.  The pharmacy notifies us that the med isn't covered, and I have to call about 17 different numbers until I can get someone to fax me a form where I put down your information and answer their questions like what your diagnosis is and what you have tried and failed.  If you haven't tried enough random medications that were cheap and just might have worked to save them money on this pricier one that your doctor who went to medical school has prescribed for you, the insurance company will refuse to cover the medication.

Isn't that fucking insane?

Despite that your doctor says, "I think you need Whatevercillin," since it costs $20 more than Whachamacallitumab which is sometimes used before stepping up to Whatevercillin, the insurance company INSISTS you try it.  Possible reactions or the pain/sickness you'll deal with until you get to something that works be damned!

One of my favorite ones is when the insurance company asks if patients with like crippling arthritis who need an immune blocker have tried aspirin.  OF FUCKING COURSE THEY'VE TRIED ASPIRIN!  IT IS NOT FUCKING HELPING, OBVIOUSLY!

But it's a normal process, so my outrage at the whole process is kind of dulled.

It does, however, get really terrible when you look at specific cases and you see how some people are suffering.

We had this one lady with rheumatoid arthritis who had it for years.  She'd tried a few things without improvement, so was going onto another med called Enbrel.  In her history she had tried a drug called methotrexate.  (By the way, methotrexate can give you cancer, but don't worry about that.)  When this lady was on it she had an allergic reaction to it which caused her mouth to fill up with sores (like a lot of drugs in rheumatology, methotrexate kind of compromises your immune system).  Uncomfortable to say the least.  So over the course of her therapy after that, methotrexate was never used.  Now, with a lot of the meds this office prescribes, methotrexate is prescribed along with them because it makes them more affective.  Understandable.  So the insurance company, in the prior authorization, wants to know if she'll be taking methotrexate along with Enbrel.  No, we tell them, she is allergic to it, as documented.  Problem is, that documentation is from years ago.  Insurance company says they won't pay for Enbrel (literally THOUSANDS of dollars, but the evil of pharmaceutical companies is another story) unless she's tried and failed methotrexate again.  So the doctor is forced to put her on it again.  Her mouth swells up.  The pain she's in from her disease (which isn't getting taken care of because she can't go on the Enbrel) is only intensified because of these crazy mouth sores.  Thanks a lot, insurance.

The thing I am currently dealing with that sparked this whole rant, though, brought me to tears this week.  We have this man with ankylosing spondylitis, one of the most unfair medical conditions I have ever heard of.  The disease basically causes your spine and pelvis to fuse so you can't move and often causes a curve in the spine.  This patient just came to us a month ago, referred by his primary care doctor, after they found that in one short year the man had LOST SIX INCHES OF HEIGHT.

So the doctor says he needs to be on Remicade, an infusible medication.  We start the prior authorization process (because Remicade is like a bagillion dollars) and they take FOREVER to get back to me, so I call them.  Turns out they "never got it."

This is a clever trick that is all too often played by insurance companies.  If there is any way for them to hold onto their money a little longer, they will.  A patient who used to work for one of the bigger companies in Ohio said they were instructed to literally throw every third claim on the floor.  That sounds like crazy exaggeration, but with the number of things that I get fax confirmations on that were "never received," I believe it one hundred percent.

Anyway, I send things again (it is possible, I guess, that it got lost or whatever) and call for confirmation.  A week or so later it comes back denied saying that the patient hasn't tried and failed and disease modifying anti-rheumatic drugs (DMARDs).  Another thing the insurance companies LOVE to do is waste paper.  They fax us the denial and then also mail it to us.  So I get the fax which is just like "DENIED, MOTHER FUCKER!  TAKE THAT!!!" but then the mail comes and it says that they are denying our prior authorization for use of Remicade for his RHEUMATOID ARTHRITIS.  WHAT THE FUCK, ASSHOLES, THAT IS NOT HIS DIAGNOSIS!!!

Yet another trick those fucks use is screwing stuff up like that on "accident."  And, of course, only putting that information in the mailed letter, so if we were a bigger office it might get skimmed over that the denial was based ON THE WRONG DIAGNOSIS because the info was already received in another form.

(Side note: If you think I'm over reacting based on this single case, consider the prior auth I did two weeks ago for a patient to up his Humira from once every two weeks to once a week.  I sent everything off and then a few days later I got both a denial and another request to do another prior auth, so, confused, I called the medical review at the insurance company who said the second request was sent on accident (so if I had just done it, I would have been wasting more time and would have never gotten a response) and that the denial was because, quote, "Well, all the requirements are here, but whoever at your office filled out the form checked that the patient would not be taking Humira as a weekly dose, so you'll have to do an appeal."  An appeal for a clerical error.  As the woman went on to tell me that the appeal process would take fifteen to thirty days from the time received, I skimmed the form that "whoever at my office" (me) filled out and found the question CLEARLY marked with a yes.  I interrupted her, "Um, I filled this out and I'm looking at it right now, and it's marked yes."  She goes on to tell me that I still have to appeal because they have a no on file.  I say, "Really?  So the patient gets penalized because someone THERE messed up?  I don't understand how the fax of the form that I filled out is somehow different than the one in front of me."  And she says she has a photo copy of it right there and...oh...wait...someone must have read this wrong...yeah, I see it...that does say yes.  So she's all, "I'll fix this and call you back this afternoon."  So, if I hadn't pushed it and forced her to look at that form, it would have been maybe another month.  Tell me that wasn't on purpose.)

But back to my dude with the AS and the denial based on the WRONG DIAGNOSIS.

I call and tell them that he's been denied based on a diagnosis that was not written anywhere on the original form I sent them and has never been in his medical history.  They say I have to appeal anyway.  I'm not all that surprised because infusibles usually require appeals.  So I write up this letter saying that the guy HAS ANKYLOSING SPONDYLITIS in big fucking bold, underlined, non-comic-sans font and go on to explain that Remicade is considered first line therapy for the disease according to the FDA (who, by the way, might be the biggest fuckers of all, but they can be handy to quote in a jam like this) and that DMARDs are not an accepted treatment for this guy's disease as they have not shown to affect the spine.  I also mention that this guy is SIX INCHES SHORTER THAN HE WAS A YEAR AGO and that this kind of disease progression warrants treatment with an infusible.  I mean, the guy is stooped over so much he's rocking back on his heals to look forward and can't move his head 

independent of his body.

And what do they do?

Nothing.

I wait and wait and I hear nothing.

So I call and the woman tells me it's been denied (but apparently no one thought to tell us.  Really, we should have been expecting it, though, right?).  I say, "Even though the medications you are requiring him to be on are not FDA approved for his condition?"  She tells me that the insurance company has its own policies about drug approval.  "And those policies are based on what?" I ask, "Could you require him to have failed birth control for his condition too?"  This might not have been fair; SHE didn't deny him, the company did, but frankly I was mad, not to mention that I was so deeply seeded into this fucked up world that reason didn't really have a place in my brain anymore.  And she took it in stride anyway by ignoring me and repeating about the policy thing.

So now the doctor is trying to do a peer to peer evaluation of the thing even though they told us we couldn't because she is a badass and no one tells he what to do!  Peer to peers by insurance companies are equally stupid, by the way, because you call them to set it up and they call back like three times to confirm different call back dates and eventually end with, "We will call on Thursday or Friday between the hours of 8am and 6pm.  If the doctor is not available we will set up another time."  Then the doctor has to talk to someone at the insurance company who is considered a "peer" but is usually someone who is not allowed to practice anymore (for whatever reason like fondling his patients or killing too many of them) and who works for the insurance company so is not inclined to be impartial.

Anyway, that's where that is at.  And I am really upset.

I don't know how involved the government should be in healthcare considering the FDA is run by the government and they are LITERALLY ON THE TAKE (I'll tell you about that later), but someone needs to be monitoring the insurance companies.  I think this case may warrant being brought up to the insurance board.