Thoughts on health care reform

Well why won't the insurance cover it?

It was a prescription for an oral contraceptive. I explained that the pharmacy benefits manager might cover the medication if the prescriber submits documentation that the medication is being used for something other than the prevention of pregnancy.

But isn't it less expensive for them to cover the birth control pills instead of the cost of a pregnancy and delivery?

Well, you think that the answer would be yes. But your medical insurance company and your pharmacy benefits manager are two different companies. The company that handles your prescription coverage has no vested interest in keeping you from becoming pregnant. They don't handle your hospital bills. Why should they worry about it? Their only job is to keep medication costs down.

That was a conversation I had with one of my patients a few weeks ago. And it's a conversation I'll have dozens more times over the remainder of this year. And next year. And the year after that.

With the passage of the Affordable Care Act and the recent court ruling that held parts of the act to be unconstitutional, we have no idea where health care reform is going. But I think we can all agree that something is going to be done. It's just that none of us know what that will be.

I don't have the answers on health care reform, but I wanted to share a few of my thoughts on the issue.

In my opinion, one of the largest obstacles to care is the segmentation that occurs between the different companies that insure the patients. One company covers visits to the physician and hospital, another company covers dental health, and a third company covers the prescription medications. There may even be another company that handles vision care. There is no coordination of care since the insurers are separate companies. Each company is primarily interested in minimizing their costs. Patient care may not always be at the forefront of each company's thought processes.

Rather than continuing down the road we are on, I think that insurers should cover all aspects of patient care. Not just one segment of it.

Patients would have one company looking out for their total health care. Medical, dental, vision, and prescription coverage all from the same company. Then maybe little Johnny won't need to try three different medications before his Singulair is covered to control his asthma and allergies because the insurer knows that little Johnny will most likely have three ER visits in the meantime and run up enormous bills that could be avoided simply by covering the medication in the first place.

At the same time, the insurer would be able to track patient compliance because they would have all of the patient records at their hands. Let's say Mr Smith is diagnosed with asthma by his physician. The physician orders a steroid inhaler and a rescue inhaler. This information is transmitted to the insurer when the physician submits their bill. The insurer is able to see if Mr Smith is filling his prescriptions for both medications on a regular basis.

If Mr Smith runs to the ER with difficulty breathing and hasn't filled his prescription for the steroid in a while, the insurer can contact the prescriber and the issue can be addressed. If the patient continues to not fill his prescriptions and keeps running to the ER or urgent care center, then the patient runs the risk of having his coverage dropped or having his premiums increased because of the non-compliance issues.

Combining coverage for all aspects of health care would let the patients know that they must adhere to the treatment plans that are designed by their providers. The days of running to the doctor, only to decide not to follow the doctor's orders are over. If a patient wants to continue to have their condition covered, they must show a little responsibility for themselves.