This diary will be more of a rant than anything else. Or at least a personal anecdote that has me fuming, so don't expect lots of linky goodness. My story involves Wellcare, one of the Medicare part D drug plans, and the scenario that has been unfolding here in my husband's medical office today.
For those who think that these private insurer plans have any interest at all in appropriate treatment for patients, follow me over the fold to find out just how infuriatingly unconcerned they are with anything other than their own profits - and how the system is stacked in favor of protecting their profits at all costs.
We started seeing a young disabled woman as a patient awhile back. She's in need of a particular medication. There only exist TWO medications of this type - one of which is cheap, and the one we put her on, which is about $300 a month. Why did we pick the expensive one? Because the patient relayed to us that she'd had an allergic reaction to the other one in the past - hives and facial swelling.
Thus begins our battle with Wellcare, her Medicare drug carrier. I filled out the paperwork to get the drug authorized, including her history of adverse reaction to the cheaper "preferred" drug, and faxed it off to them. We got a statement back from them that she either has to have a trial ON THE DRUG SHE IS ALLERGIC TO, or we must supply documentation that she was previously allergic.
Problem. There is no documentation. The reason she came to us as a new patient was because her previous doctor here in town died unexpectedly. To date, things are still a mess, there is no one to contact at his previous office, and we have been unable to obtain previous medical records on her or on any other patients from that practice. I tried to explain this to one of Wellcare's phone reps, and was told this was "policy", and there's no way around it.
Today hubby called them himself. He explained that he was a physician trying to get through to someone who could override and do the authorization for a medically necessary drug. He was transferred a total of 4 times. He began to get angry. He kept asking to speak to either: a) a pharmacist in charge, or b) a medical director.
He was refused. Not just the authorization, mind you. They refused to allow him to even speak to anyone higher up, with perhaps a pharmacist or MD degree, who might better understand why it is not exactly safe to ignore a patient's verbal history of a drug reaction simply because it's not "documented".
He went round and round, for 15 minutes. The phone reps could not answer a single question about the drug, what it was for, the risks of being without it, or why it might be DANGEROUS to "try her for 6 weeks on the alternate drug" as they kept insisting he do. Except when pressed, they denied responsibility for saying that it was safe or unsafe for the patient, only that it was "policy", there was "nothing they could do", and there was no one else he could speak to about the matter. I want you to understand - there was a stone wall erected with phone reps reading the "policy" verbatim, and zero recourse to speak to anyone else if you are unsatisfied with the answer. Not even if you are a physician with a very sick patient.
Hubby is sitting in his office right now - still furious, still banging his head, trying to figure out how the hell he is going to treat this patient. She can't afford the medicine that works. She can't take the other one.
We do this all the time. I could come up with dozens of stories just like this one. We need to get the profit motive OUT of healthcare, period. Private insurers have zero interest in patients getting good care, and they've proven that to me over and over, every day, for 15 years.