Thursday, February 24, 2011

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.

8 comments:

Anonymous said...

Good idea, but the only way that consolidation of records will happen is most likely under a single payor type system which is a politically non-viable option at this point. Nope, Congress will handle this situation like it handles any other. Posturing, blaming, blowing smoke, and waiting to see which way the wind is blowing on this issue after the 2012 elections.

Eric, RPh said...

Some of the insurers handle medical, dental, vision, and prescription coverage (in my area Aetna and a local company do) so it can be done. The Aetna insurance seems to cover everything in a reasonable manner.

I am not advocating a single payor system. In my opinion that would be the death nail for health care and the United States would no longer be the leader when it comes to medical innovation.

PAS said...

One caveat, and I bring this from dealing with a very wide variety of plans. The BCP example. The 'default' commercial formulary offering most PBMs offer in the insurance world includes such things. They tend to be quite liberal, assessing only a brand/generic copay, and declining to tier such drugs at higher levels (with rare exceptions such as the Beyaz retardation). However, these formularies are then sold to sponsors of plans: employers, unions, groups or trust funds.

Since the sponsor is underwriting the risk of the plan, and paying the costs associated with it, they have the prerogative to modify what is included in the plan and excluded. Erectile dysfunction drugs, drugs that are injected, and BCPs are unfortunately often targets of this. The degree to which most PBMs sales teams will go to cater to the every retarded whim of a sponsor is utterly sickening. I know for instance of one PBM, a small one, that made it's niche developing an extremely modular drug formulary, that allowed different classifications of medications to be swapped in and out readily. While the drugs were 'in' the developed formulary, whole classes could be snapped in and out like accessories.

Interestingly enough, some of the technology you're describing already exists. The software system I work in, for instance, has an entire suite of software that can be added in to make claims data interact with providers, or administrators in close to real time. There's a web system that quite literally allows an MD to query up a member and view their claims as they exist in the PBMs software. It's profoundly powerful stuff, and goes so far as to allow the actual billing of 'test' claims to adjudicate them in real time according to the benefits in their current state.

PAS said...

I agree that the ability to reconcile medical and pharmay side utilization and costs would be ideal. In principal, drug coverage on the pharmacy guidelines are based on the guidelines that clinical practice follows. Most MDs follow these, however, as most in pharmacy at any level can tell you, there are enough folks out there writing scripts for whatever shiny logo the drug rep has paraded around that it destroys the good faith. Like drug addicts do for chronic pain patients, crappy prescribing destroys the blind faith in clinical judgement prescribers would otherwise enjoy.

Prior Auth is a crude and flawed solution to this. If we could see medical records and information as you describe, this would be a FAR different matter. But we can't. So we fall back on outright terrible communication skills. On a literal daily basis for Advair(to follow the asthma example above) I ask, 'Is this patient inadequately managed with daily usage of an inhaled steroid?' the answer is always 'yes' and he inhaled steroid they're using is always albuterol. Or Spiriva. At this point I go and dig back through a couple years of claims history - maybe they got a Qvar, or Flovent. This invariably fails as well. And never mind that the majority of these Advair inhalers come with a PRN sig.

However, there's much blame to go on the PBM side as well. More than one sponsor has demanded modification to guidelines, commonly stripping out any leeway for the judgement of the RPh making decisions on them. Many plans demand faxed only submissions (again, Sponsor - the PBM would happily sell them phone service for PA). Many of these forms are just atrocities, if specific forms even exist. Combine that that with many MDO's staff being unable to handle basic sentence writing, and there's a good reason why the MDO calls the fax a denial machine, and we call it the MD's commode (in much less polite terms).

The basic gist is that at the moment, a plan sponsor has unreasonable amounts of power over a plan. They will frequently cherry pick, or 'carve out' different benefits to different entities. Since PBMs, and to a lesser degree our medical counterparts are desperate for a sponsor's business, they will readily agree to the most ridiculous setups. I've seen pharmacy plans set up that cater only to specific retail pharmacies (as few as ONE actually), to them being subdivided by classes of drug - and this is what really needs to stop.

One of the reason some of the better MAPD plans have been so successful is by using a degree of the integrationyou describe. Nothing as thorough, but plan leve MTM, RN case workers, and a strongly carved IN pharmacy benefit (where the Rx plan is firmly part of the whole ins, like Aetna, or old PacifiCare), with liberal guidelines has been remarkably successful.

Anonymous said...

To the the above poster. Great post!

Digital real-time formulary information at prescriber level is the now/future and will allow a greater continuity of care for patients.

Anonymous said...

Just to share a random comment on birth control cost. My prescription has sky-rocketed to $67.99/pack (US dollars.) This is ludicrous! I am confused over this increase...and fear what is to come with pricing in the future.

Anonymous said...

PAS - Sorry, I don't agree with your slam on prescribers.

First, albuterol is not a steroid. It is a sympathomimetic bronchodilator.

Also, it is not unreasonable for an asthmatic to have a prn sig for Advair. Often, in clinical practice, an asthmatic might need an inhaled steroid during certain times of the year, winter for example. Patients are instructed when they get an exacerbation of their disease to use it bid for 1 month, then stop & just use albuterol. This is a common approach for young adults.

For COPD, its a different matter - bid along with a bronchodilator.

But, these are two different illnesses! The drug should not always determine the sig - the disease should. For insurers, they just see the sig, which must be in a simplified format to condense on a prescription label. However, as a clinician, I educate based on other information from the prescription. An insurer would only find this information on an audit.

btw - I practice in a clinical academic setting where we not only provide prescription drugs, but also use these same drugs in clinical trials....

Finally, although insurers like Aetna, Kaiser & Healthnet do coordinate claims, the employer or patient might change insurers over time. In the last 5 years of my own job, I've had 3 different insurers. I wouldn't rely on the insurer to have my best interest at heart. My physicians & dentist have remained the same for 20 years.

electronic medical records said...

Well, there are so many thoughts on health care reform, Wish that all this thoughts will combine all together and make a good result for health care reform.

-mel-