The quality of the healthcare you receive in the United States is determined by your income and the terms of your employment contract. Why not? It is delivered by for-profit corporations for the benefit of executives and shareholders. Again, why not? American healthcare outcomes are not among the best in the world, though they are pretty good for many Americans who have decent health insurance plans through work. American healthcare is, far and away, the most expensive, and the most profitable in the world, so that’s something to be proud of, isn’t it?
I got the good news and the bad news yesterday about my kidney disease and the $88,000 treatment I might need in a few months. The nephrologist’s receptionist called with good news that my recent tests came back rosy and that I don’t need another round of the fancy drug at this time. The bad news is that the doctor won’t be picking up the phone, he told his receptionist to tell me he’ll give me all the details when I see him in a few weeks– three days after my deadline for purchasing health insurance for 2019 — and that we’ll test again in three months. He emphasized to me at the beginning that this idiopathic disease is unpredictable and little understood, numbers can go up or down dramatically at any time and we cannot put much faith in patterns like the steady downward tic of the concerning numbers.
I called back today to ask to speak to the doctor for a minute. Sadly, not possible. I explained my insurance dilemma to the receptionist, that my deadline for choosing insurance for 2019 is three days before my appointment. I told her I didn’t want to put her to any extra work but that I needed to know if they were likely to get pre-authorization for a drug that would cost me $88,000 “out of pocket” if it wasn’t pre-approved. The alternative, the longtime standard protocol for my disease until this new wonder drug came along, is a much cheaper but more debilitating twelve month course of intravenous steroids and infusions of a more harmful immunosuppressive agent (as opposed to two infusions a month apart). I’ll ask the doctor for you, she said. I hope to hear back in the next few days, though, of course, one never knows. Only the weak and fretful worry about these sorts of things…
I called the insurance company and punched in the option for pharmaceuticals. Spoke to a very knowledgable rep there at the third party that pays drug claims for my insurance company (and many others), explained my dilemma. She told me, after a long investigation, that since this drug is not sent directly to the patient but administered in a hospital, I had to go through the medical department of my insurance company, that this drug did not fall under “pharmaceuticals”.
I explained to her that during my previous hour long call the medical department had referred me to her company, the third party that approves all pharmaceuticals, including hospital administered ones. She told me this was not the case, that somebody at the insurance company had made a mistake. I read her back the provider-side 800 number I was given by her company for pre-authorization. She agreed it was the proper number, the number my doctor would have to call to get pre-authorization for this drug. I told her it had taken me almost an hour to get that number but that it was not one I could call myself, being a patient, not a provider. I was patient as hell itself. She gave me an 800 number for patients to call for “Speciality Drugs” and then noted that I seem to have spoken to someone there last week.
I explained to her again that my worry and my question both appeared to be fairly straightforward. In 2017 I had a QHP and Rituxan, the $88,000 drug, had been approved. In 2018 I was on a lower tier plan, and it was uncertain whether Rituxan could be approved, particularly since it was on the “excluded list”. “Unless the hospital gets pre-authorization,” pointed out the helpful rep. She was unable to determine whether it was also on the excluded list for the QHP.
She simply could not tell me if in 2017 the drug was on the “excluded list” and had to be pre-authorized. If that was the case, it would give me some comfort. In other words, I was trying to determine whether the insurance product I was about to be forced to buy for 2019 would cover the expensive drug I might well need in 2019. Not a very tricky question, outside of an unregulated corporate environment where the primary concern is maximizing profits and the health and well-being of patients is on an as-needed basis.
The confusing labyrinth of disconnected and walled off corporate sub-offices is perfectly allowable (and virtually unregulated) under the terms of Obamacare and under the “Business Judgment Rule” (a given business is in the best position to make judgments about how it should be run). These internal walls make it impossible for anyone within the corporation (or outside of it, for that matter) to have a global view that would allow them to answer a fairly straightforward question about what products and services are covered under a given plan. The rep seemed a little offended, telling me she’d been working there for many years and had a pretty global view, but that I was asking a question that was just impossible to answer.
The bottom line, it will take a lot longer than two hours, if ever, to get the answer to this simple enough question. The helpful rep who tried to help was sorry she couldn’t give me the answer I was seeking, but it was simply impossible. She could take a grievance from me, if I liked. I declined her kind offer and thanked her for her time, somehow not giving vent to the bitter sarcasm that was flowing over my tongue like battery acid.