Things can go wrong after you get health insurance
The doctor-insurer interface is harsh, it wastes time & money
Insurers are often penny wise and pound foolish, including public programs
I review four scrapes from the first 2 weeks of the New Year.
- A girl (E) discharged from our hospital after surgery for a brain tumor (craniopharyngioma) was readmitted for avoidable dehydration. Surgery injured the pituitary and hypothalamus, leaving her dependent on replacement hormones. However, she ran out of an important hormone, ddAVP or desmopressin.
What happened? ddAVP was a nasal spray. Mother ran out before the month was up. The pharmacy told her that they could not give her any more medication for 6 days. Lack of medication caused excessively dilute urine, dehydration and an expensive hospitalization. MediCal (Medicaid) pays for only a 30-day supply. The pharmacy had three choices- 1. Give her some of this expensive medication and lose money (at least $100), 2. urge mother to call the child’s physician immediately (that might not have worked as mother met many different specialists while hospitalized and had no idea who was in charge). 3. throw up their hands and say “we’re sorry”. They choose #3.
There is usually some spillage with liquid medications and sprays, but Medicaid insists that a patient get 30 ml of a solution that she will take 1 ml of each day. It’s impossible to say exactly what this hospitalization cost, but it cost thousands and Medicaid paid thousands. There was also some risk of permanent additional injury from severe dehydration, which seems not to have occurred. Penny wise and pound foolish
- A few days later, I received an anguished call- F ran out of his seizure medicine after 22 days and the pharmacy won’t give me any more. Again a liquid medication and spillage- no seizures had occurred. I changed the child to a tablet form, explained to mother how to give the crushed tablets with food and all was well. If mother had not called, hadn’t known who to call, seizures might have occurred, maybe causing another avoidable hospitalization.
- I saw G in our emergency room after her third unprovoked seizure. She didn’t need hospitalization but more seizures were likely without starting daily antiepileptic medication. She is covered by an HMO that won’t pay for their members to be seen at our hospital. She has a primary physician or PMD. I hate to prescribe medications for someone whom I won’t see again because these drugs can cause serious side effects- allergic reactions are fairly common and will get worse unless the medication is stopped. They need some supervision. Lawyers say “don’t take that risk”. However I thought that the least bad thing was to give the child a 30 day prescription for a seizure medicine and send a FAX to her PMD explaining what I had done and his need to see to it that the medication was refilled, that the child was not suffering obvious side effects (I mentioned the main ones) and have the child see someone expert in pediatric epilepsy. I sent a copy of the FAX to mother.
32 days later mother appeared in our emergency room at night out of medication. There was no seizure. I was called at home and told the ER doctors to give her a one-month prescription, and get mother’s phone number. When I called her, she said that the PMD (who is being paid to “manage her care” whether or not he sees the child) told her “I am not a specialist; I don’t know about these things, you can go to the ER and get more medicine”. I called the PMD and told him that I had told mother to contact her congressman and a protection and advocacy group. He denied telling mother to go the ER but admitted that “I’m not comfortable with those medicines”. Note also: his HMO is not charged for ER visits due to a “carve-out” political deal. They have a strong incentive to send every problem to the ER. They do not compete with public medicine (straight Medicaid) on a level playing field.
- Patient H has severe epilepsy. In December I spent much time on the phone to get his insurance to approve the most expensive of his 4 medications. Thirty days later, I get a FAX from the pharmacy saying that the 2nd most expensive medication (topiramate) is “non-formulary” and requires authorization. So I call and ask why did you approve this medication last month and now you balk? “That medication is non-formulary as of Jan 1”. We discussed this and they FAXed me a form. I completed the form, attached copies of recent patient reports to show that this child had life threatening epilepsy and recent hospitalizations for seizures out of control. I waited 24 hours & heard nothing. So I called the PBM and asked what about approval? Ans- you didn’t send the right form. So they FAXed the form- exactly the same form that they had FAXed earlier. So I FAXed back the first form. Then they said that I had an incorrect insurance number – a ten-digit number. I sent them a copy of a letter that they had sent in December approving the other drug and listing the insurance number that I had used. This merry-go-round continued. I spent about five hours that week on this mess- never getting approval or denial. Every day I received an automated FAX from the pharmacy saying “your patient’s medication has been denied by _ because it is non-formulary” Please call ** to obtain prior authorization. By Friday I was boiling. I called the pharmacy and asked to speak to someone in charge. She said, “Yes, that sometimes happens to us, they refuse to authorize or deny the medicine and just leave us hanging. I asked about a California state agency that might pay for this drug, even without an insurance denial. She said yes, call *** and ask for ***. It worked- H got his medication. However that agency faces a 10% cutback due to California budget problems.
These children were all covered by insurance, 3 by some form of Medicaid. Patient F is white and has private insurance. Suppose that the Clinton, Edwards or Obama health plan magically became law through persuading Congress to vote for something expansive and expensive. Would any of them prevent these outrages? It is logical for a profit-making company (only E received nonprofit care) to control costs by restricting amount and frequency of prescriptions. Republicans say “count on the free market to cut costs”. I spent 5 hours on H’s case, which was “friction loss”, heat produced in the process of getting a needed result. If I were a young physician seeing this stuff every day I would seriously consider a career change - or maybe going to work for a drug company. We often forget that the success of education and healthcare depends on teacher morale and doctor, nurse, etc. morale (I detest the phrase healthcare provider because I don’t think that we are selling soap or used cars). In reality, teachers, doctors and nurses have less freedom and more paperwork than a generation ago, and this will continue. We must reward those who rise above the crap and give extra time and effort helping people, and keep the focus on patients, not “cutting costs”.
Consider also the effect of big loans on young doctors, at a time when inflation-adjusted reimbursement per visit is declining and Medicare plans to reduce it further... I am old and have no debts. If I owed $150,000 I would probably be much more mercenary. US healthcare can only make small improvements so long as doctors start out saddled with massive loans. The government should cover the cost of their training in return for an 8-10 year payback. The sanctimonious healthcare gurus should spend some time in the public hospitals, jammed to overflowing, ER patients waiting until a patient is discharged before they go upstairs. Teaching hospitals have laid off social workers like the public schools laid off music teachers, and for the same reason.
Reconciliation with reality: I hate private insurers (I note that the state of California is asking up to 1.3 billion dollars in fines against PacifiCare for delays and denials in claims processing-see www.latimes.com/business/la-fi-insure29jan29,1,2413322.story?ctrack=2&cset=true. The state says that 30% of claims reviewed were improperly denied) but I remind you that cost control is necessary in any healthcare system- nowhere in the world do people get everything that they want or need. The richest 1% can buy what they need, but most people can’t dig up another $10,000.
My four patients got a better deal, frustrating though it was, than they would have gotten in Mexico or most Latin American countries (less good than they would have gotten in Canada). The irony there is that most Latin American countries promise healthcare as a basic right, but don’t try to deliver it. S-CHIP is better than no insurance, although it would put more people into this frustrating morass. My examples relate mostly to prescription drugs which account for about 10% of total national health expenditures. Those who want details can read content.healthaffairs.org/cgi/content/abstract/27/1/14. These cases relate also to our fragmented healthcare and the simultaneous over- and under utilization of specialist care. Intelligent primary care, like Western civilization, is good when you find it.
How then to reconcile finite health care resources with human needs? That’s tough, but not impossible. Rather than drag out this diary, I’m planning another diary, “The costs of cost containment”, but it must wait until after February 5th because of Obama commitments.