I spent a large part of Monday at the hospital where I now work as a part time volunteer pleading with an insurance company.
I do this as some of you know, so I'll get an inside look at the American healthcare catastrophe.
But one can easily read the headlines to see the tragedy unfolding around us with no relief in sight. This is what USA Today reported in a demoralizing story entitled, Prices soar for cancer drugs
Spiraling prices for new cancer therapies -- up to $10,000 a month for a single drug -- are causing alarm among patients and insurance companies.
"These costs are out of control," says Fran Visco, president of the National Breast Cancer Coalition, which is planning a conference focused on drug costs in the fall. "We can't allow it to continue."
http://www.usatoday.com/...
I'm trying to get an insurance company to approve a second course of Avastin for a very sick woman with metastatic endometrial cancer so this story resonated with me.
The cost of a cancer drug prescription rose nearly 16% last year, compared with 3% for other prescriptions, says a June report by Express Scripts, a pharmacy benefit manager. The average cost of a 30-day prescription for cancer drugs is now nearly $1,600. The report does not include drugs given at a doctor's office, such as Avastin.
Barbara Brenner of Breast Cancer Action says she is especially troubled by the cost of Avastin, a newer drug used to treat colorectal cancer that now sells for about $50,000 a year. That price could jump to $100,000 if Avastin is approved to treat breast and lung cancers, because those tumors are treated with higher doses of the medication.
"It's really exploiting the desperation of people with a life-threatening illness," says Marcia Angell, former editor of The New England Journal of Medicine.
Cancer patients and their doctors are terrified. This is happening across America to millions of our fellow citizens.
Tarsha Echols, 34, a flight attendant in Memphis, began taking Herceptin last year to keep her breast cancer from returning. That was before her employer cut her salary 35%. She plans to stop taking the drug Monday -- a year early -- because her health plan now requires her to pay 20% of her medical costs, or about $800 a month. That's more than her rent. "I hope that whatever I've gotten so far is enough," she says.
I understand the terror a bit better now that the health care catastrophe is no longer a blur of numbing headlines. It is about real people like Sara.
The first diary I wrote about her medical crisis was, Looking into the eyes of a dying woman. If you'd like you can read it here:
http://www.dailykos.com/...
This is from the memo I wrote to Sara's doctor summarizing the work I did on Monday. It recounts my tedious progress with insurance company clerks and one pharmacist in obtaining approval for the Avastin.
For reasons that should be obvious, I'm leaving out the name of the insurance company and the prescription benefits manager.
7/10/2006
1. Spoke to Penny in -----pharmacy management. She told me the request had to go through medical benefits but that since it was an IV product, ------ would be involved. -----, I asked. Why didn't anyone tell me about ----- when I called ----- last week? No answer. Penny checked the ----- computer (linked to ----- system) and told me Sara is a ----client.
2. Transferred to ------. Amy on the "miscellaneous team". Told Amy I was in search of outpatient IV Avastin. She said, for what condition. I said, cancer. Amy told me, "you want the chemo team". Got transferred to Helen on the chemo team. Gave her all of Sara's data, she told me, Sara is not in the system.
Told this idiot (Helen, chemo team) that it was confirmed by Penny at ----- that Sara was in system. Put on an endless hold. Ms. Helen returned and told me maybe she was never entered into the system. Transferred me to Allison B. in customer service. Note here: the sleigh of hand, the difference between being in system and being entered in the system.
3. Gave Allison B. all Sara's information. She opened up an account for her--entered her in system. Told me Sara never used ------Specialty Pharmacy hence never entered into system. Now Sara is in ----- system. Are you following this??
4. Transferred me to Barbara a Pharmacist. Tele: ----- . This is when J.called because Barbara needs to know the quantity of Avastin you want to order.
After you work out exactly how much you want (if you order a lot and want to increase the dose, you can then order additional "vials"), ----- will submit the prescription to ----- for the "verifiers" to approve. ------ will try and get the prescription approved. They will also advise Sara of any cost. They will ship next day air wherever you direct. It is shipped on ice. Pease ask me for clarification on anything.
Summary
1. Sara never activated her -----benefits. I entered her in system
2. Don't know if the prescription will be approved, but in any event, she is required to go through ------ for this medication.
3. If she is not approved -----will give you a form to submit to show that the drug helped her. This will move her to appeal.
4. We can also ask Genentech for assistance with the appeal if necessary.
End of the day, I think the reason she paid so much last time for this drug is because she didn't go through -----. Don't know how the off-label use will impact all this--stay tuned.
Time on the phone: Approximately 1.5 hours. Now multiply this by let's say 100,000 cancer patients, their doctors doing this every single day. Feel like I'm writing a Kos diary.
God Bless America.
xxeve
Why didn't Sara activate her pharmacy benefits? Good question. Like many Americans, she was undoubtedly unaware that she had to do this.
Being confused by all the rules and regulations is not uncommon. Being very sick is also a full time job. So she made a mistake and paid dearly for it. She paid a staggering amount last time she needed the Avastin.
But frankly an equally important question for me is: why didn't the insurance company contact her and explain that she needed to go through the prescription benefits manager.
Why didn't the numerous insurance company clerks I spoke with last week when I began this odyssey on her behalf, tell me I needed to contact the PBM? Why when I resumed calling this week, did one clerk tell me about the PBM in a totally offhand comment? I'm healthy and after I finished, I felt like I needed a bath and a tranquilizer.
I expect even though we are now following all the procedures she will get turned down because her doctor is prescribing Avastin for off-label use.
Like the impossible-to-use Medicare D, why is this system so daunting in its complexity?
Finally, when we submit clinical documentation and demonstrate to the insurance company that the Avastin dramatically reduced her tumor during her initial chemotherapy will they deny her coverage?
If they do resist, and she can no longer afford to pay out-of-pocket then . . .
I don't know. I have no answer.