Do you know anyone with health insurance headaches? Or maybe the question should be: do you know anyone who DOESN’T have health insurance headaches? With over 100 separate health insurance companies operating under different sets of rules, we have created a bloated, unwieldy and unnecessarily expensive delivery system for healthcare that promises problems for anyone using it, provider and consumer alike.
Pharmacists have been hit hard by our for-profit, 3rd party system. Pharmacy blogs and online articles abound with stories of inefficiencies that make a hell out of every ten-hour shift. But most importantly, the system endangers the health of the people it purports to serve. I read one account of a pharmacist whose staff spent a total of seven hours on the phone trying to get approval for two simple prescriptions. Another pharmacist made this comment on a blog recently: “To get a claim processed, we had to bill one insurance policy, get a rejection, bill a second insurance policy, get a rejection, THEN bill a government-funded insurance with several override codes to get the claim to go through. There were only myself, one tech and one pharmacist who knew how to get this to go through without problem every time.” Another blog comment tells the following tale: “I recently had someone bring in a prescription for an expensive antibiotic and it rejected stating that the insurance does not cover it. I called and spoke to someone who was obviously in a foreign call center. They told me that another similar drug was the “preferred” drug for this patient’s plan. We called the doctor and got it changed to the “preferred” drug. We then tried to run it again and it rejected for the same reason. I called the insurance back and the rep I spoke to this time simply stated that the first rep I spoke with was wrong and that neither of these drugs are covered.” I had a scare myself some years back when I was told that the $900.00/month drug I take to stay alive would no longer be covered by insurance. Repeated pleas to my HMO renal social worker got me nowhere. It was a pharmacist who finally took the time to straighten the mess out and restore my coverage. God bless him.
Pharmacists will be the first ones to tell you they are capable of doing much more than counting pills – they are the experts on the drugs we consume. In most cases they know a lot more about your prescription that the person who wrote it for you. They should be spending their time educating providers about the best medications to prescribe and counseling patients about how to take those meds safely and effectively. Pharmacists are talking about expanding their role and setting up specialty clinics to advise patients with HIV, diabetes, heart ailments, cancer and other diseases. They should be free to concentrate on high-value activities, such as drug dosing, adherence, and medication adjustment. Instead, they’re using their valuable time and skills to argue and coax insurance companies into doing what they supposedly already exist to do – provide medical care to the insured.
Here are some hard truths: with our private medical insurance system we spend more per capita on health care than any other country in the world, over twice as much as most other developed countries. Yet some 47 million people in this country are without health care and, according to the CIA World Factbook, rank #36 in life expectancy, just above Slovenia. Slovenia?! Where quality of healthcare is concerned, the Commonwealth Fund Commission’s National Scorecard on U.S. Health System Performance gives us 66 out of 100 points across 37 indicators of performance. Scores on efficiency are particularly low. No wonder that in 2007 we spent an astonishing 2.2 trillion dollars on healthcare costs. Medical News Today, an online compendium of medical health news, says, “America is the country where people spend the most on healthcare and live the shortest amount of time, when compared to Western Europe, Japan, Australia and Canada – that is, the rest of the developed world.” For the first time in American history, the life expectancy of American children is less than that of their parents. In short, people from other countries enjoy a much higher level of general health than the best privately insured Americans.
Our healthcare system is administered by insurance companies whose loyalty is to shareholders and to the bottom line. They make profits by denying care to patients and every day nurses, physicians and pharmacists go to war against them to procure equipment, tests, medicines and care for their patients. Obama’s healthcare reforms may right a few of the wrongs in the system but don’t address the essential problem; the US healthcare delivery system is made up of insurance companies that profit off the rotten luck of their customers. This is the third rail Congress members don’t want to touch and the companies lie to us about. And until we oblige them to come clean about not just the economics, but also the ethics of such a system, there will continue to be some bad days ahead for the rest of us.