Let's start with just trying to sort out where the problems begin. First of all, a patient becomes ill and goes to see the doctor. Through the doctor's expertise and years of medical school, he gives his diagnosis, prescribes the therapy, medicine or intervention and said patient is off on his way. Not so fast! No longer is it a matter for the doctor to decide alone.
It seems that there is a whole lot of red tape to go through before that can happen, at least in most cases. Some first hand examples to share with you may clear this up, in case you have had the good fortune of not having to deal with any of this due to your excellent health. (or maybe you need to drop me a comment so that I can check into the insurance that you have, just in case I may qualify)
A few years back was my first experience with an insurance company policy that was most definitely on the inane side of a business. And I may add, a business who is highly compensated for what they provide. Being a woman going through all kinds of 'the changes of life,' I was having a problem with pimples. Yes! Pimples, like the kind that poor teenagers have to deal with. Apparently, it is a common symptom for my gender and age, so my doctor prescribed a cream to use on my face to deter pimples. Nothing that I was using from the over the counter medicines was working. I dropped off the prescription. The problem started when I returned to pick it up from the pharmacy. The pharmacist called me over to the consultation window where they can talk to their customers privately. He leaned over to me and said that he was sorry, but my insurance would not pay for this acne medicine because in their words, not his, I was too old.
This was the stage setting where I had my 'southern come-a-part.' Not at the pharmacist and I did explain this to him. It was the fact that someone sitting in a chair at a desk or in some little cubicle thought that he knew better than my doctor as to what medication was needed? And he had not even seen me? He based this on only teenagers get acne? I worked on breathing in and out slowly in order to ask my next question, which was, "What can I do about this?" The pharmacist told me that the doctor would have to call the insurance company to explain this to them. Again, I was having to control my annoyed state of mind, thinking to myself, that my physician was going to have to take time out of his day to call this guy who definitely was too big for his own britches to tell him why he prescribed this medicine to me.
Well, yes, my wonderful doctor did make the call, and I did get the medicine the next day. The pharmacist told me that the insurance companies were questioning doctors more and more. I suppose there are some bad apples in every profession, however, I am also sure there is a better way to keep tabs on doctors and the prescriptions they write.
Since that time, I had to deal with a very expensive dry eye drop medication that was prescribed to me. The pharmacy said that I needed to call the insurance company before they could fill it. I did call them and after going through the robo-voices of push this button if you are a patient, push that button if you are a physician, press two and then the pound sign if you want to continue...really? My belief is that they put you through this just hoping that you will give up. Well, give up is not in my vocabulary at this stage. Finally, a live human being came on line with a very heavy foreign accent and he told me that his name was Bob and asked how he could help me. Aha! Just like one of my previous blogs - customer service = oxymoron!
When I told him my problem, he informed me that the eye doctor would need to call for a prior authorization. After the insurance company gathered the information, then a meeting would be held to determine if the insurance company felt it was compelling that I use these drops. This was totally outrageous to me. The insurance companies have become Mr. Big Stuff, Who Do You Think You Are? Well, I can tell you that they have the power to do whatever they want. Is it right? NO! Is it legal? YES! Is there anything that we as the consumers can do? Yes and No! We can watch our public elected officials and vote out those who allow this to happen through the insurance lobbyists. This will not be an overnight process.
Another process to go through, is to establish communication to employers about the providers that they use and the wording that is in these insurance contracts. This is not an overnight process either. Doctors need to get involved also. They are now being asked to spend their time, or hire someone to take care of individually calling to verify their diagnosis and receive prior authorization concerning prescriptions to some business person who does not know 'Jack Sprat' about the patient. Perhaps the AMA could begin lobbying in Washington as hard and often as the insurance companies do. Doctors do not need to have headaches over this ridiculous and demeaning procedure.
This past summer, I became a breast cancer survivor. When the process of the biopsy, surgery, radiation treatment and medical oncology all started in the stages that they all take place, I received a letter from my insurance company. The letter stated that I needed to be sure that the physician called them first to get a prior authorization so that they would approve what was being done to me. If the doctor did not do this, then it was explained to me that I would be responsible for the total amount charged. This came to thousands of dollars. It did not matter that my insurance claimed that I was using a doctor that was in their network. They wanted to be sure that he was prescribing what the insurance company felt was the right interventions.
I believe that it is time that we all became more involved in the field of insurance companies. They are charging employers so much that there are companies who are dropping this benefit to their employees. Then what? Now is the time to start shrinking Mr. Big Stuff down to the size where he belongs.
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