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The insurance maze

Pharmacists say they’re spending less time consulting with patients and more time researching which medicines qualify for coverage
Saturday, June 16, 2007 | 2:00 a.m. CDT; updated 9:17 a.m. CDT, Tuesday, July 22, 2008

Pharmacist Bill Morrissey is spending more time these days giving customers unwelcome news: Their health insurance provider refuses to cover the cost of their prescription.

Morrissey, owner of Kilgore’s Medical Pharmacy at 700 N. Providence Road, says he sees the problem all too often and says it gets worse every year. The problem, he says, stems from a confusion about which medications insurance companies will cover.

Most insurance companies have formularies, or lists of different medicines in a particular class. Though these drugs are identical or nearly so, the companies cover only a few because of better deals they get from drug manufacturers.

To keep prices down, most insurance companies change their formularies every year, sometimes more frequently. Morrissey says most plans provide patients with lists of commonly prescribed drugs and also have Web sites with similar information. Because the information changes so often, and because those lists are far from all-inclusive, most doctors and patients simply can’t keep track.

So when a patient arrives at Kilgore’s with a prescription that isn’t on the list, Morrissey hops on the phone to either the insurance company or the doctor, sometimes both, to change it to something that is covered. With several layers of management at insurance companies and local doctors fielding calls from all of Columbia’s pharmacies, that process isn’t quick.

Morrissey says that every case is different, but on average he spends at least 15 minutes trying to fix one of these problems. Those little blocks of time add up, and a large portion of his day is spent on the phone.

“You spend more time talking on the phone, rather than actually talking to the patient about the medicine they’re going to get, what side effects they can expect, different things they can change, lifestyle-modification-type stuff to improve their health,” he says. “You feel more like a billing clerk than a pharmacist.”

Many large insurance companies say formularies simply save money. Humana spokesman Jeff Blunt says formularies, by driving people toward cheaper drugs, are an effort to “ratchet down health care costs” for both patients and their employers.

Most of Humana’s plans, for example, categorize drugs into four tiers of coverage based on a drug’s effectiveness, cost and availability of a cheaper alternative. Blunt also says that Humana provides patients information about which drugs are covered both before they sign up and afterward.

Triston Brownfield, a pharmacist at D&H Drugstore at 1001 W. Broadway, also says that confusion about insurance coverage is a problem. He says his frustration level increased “two-fold” last year after the federal government began Medicare Part D, which subsidizes prescriptions for seniors. In April 2006, the Wall Street Journal reported that 26.5 million people were enrolled in the program. Brownfield says that with that many people switching to various coverage plans, confusion about which drugs are covered is inevitable.

Morrissey and Brownfield are two of more than 220,000 retail pharmacists nationwide, according to data from the U.S. Department of Labor’s Bureau of Labor Statistics. These pharmacists work in hospitals, grocery stores, locally owned operations and chain pharmacies. In addition, more than 250,000 pharmacy technicians help by entering prescription information into a computer system, answering phones and getting drugs ready for pickup.

Both Morrissey and Brownfield say insurance frustration is an industry-wide problem, so each of these pharmacists or pharmacy technicians must deal with it daily, reducing consultation time between pharmacists and patients.

Tricks of the trade

When Morrissey was in pharmacy school about 10 years ago, he recalls attending a few lectures about insurance industry basics, but he never heard the word “formulary” before he started as a pharmacist.

Kathleen Snella, the assistant dean of the University of Missouri-Kansas City pharmacy school, says that aspect hasn’t changed. “The biggest place they learn how (to deal with insurance companies) is when they’re in the fifth year of their clerkship in clinical rotations,” she says. “That’s where they’re learning the day-to-day ins and outs.”

Although he didn’t receive much training, Morrissey says he’s learned a few ways to get around the insurance industry roadblocks, such as helping a patient with his cholesterol medicine. To reduce the number of pills he has to take, the patient’s doctor wrote him a prescription for a drug that combines his regular medicine with a vitamin. His old medicine was covered, but the new one had a high co-payment. Morrissey and the patient did the math and the patient decided to stay on the existing medicine and buy a bottle of 100 tablets of the vitamin, a three-month supply, for $5.

Some patients come to Kilgore’s with a prescription that isn’t covered, but a generic version’s co-payment is around $10. If a pharmacist pays close attention to drug prices, he or she might notice that the price for the generic without insurance is $12. Instead of filling the original prescription, the patient can pay the extra $2 and skip a lot of hassle.

“After doing this for a few years, you could say, ‘Well you know what, it’s only going to save us $2 to go see the doctor and get this approved, why don’t we just pay the $12 and worry about it later?’” Morrissey says. “If you’ve got the sick kid there, you’re going to say, ‘Sure.’”

Morrissey says he learned some of these tricks from other pharmacists. He’s picked up others from experience. He says younger, less experienced pharmacists often don’t know these maneuvers and aren’t able to “finagle” the system.

Brownfield stresses that there isn’t a solution to every problem.

Sometimes insurance companies require patients to try older, less expensive medications before they will cover a newer, more expensive one. A doctor who wants to prescribe the newer medication then has to send medical information — called prior authorization ­— to the insurance company so they will cover the medicine. Some of these drugs might include newer, more advanced heartburn medications such as Nexium or advanced nausea-reducing drugs for chemotherapy patients.

“There are some cases where there isn’t a good alternative,” Brownfield says.

But if a patient is discharged from the hospital on a Friday or a weekend and needs that prior authorization, many insurance companies might not act on the request until the following Monday. For chemotherapy patients experiencing nausea or those with severe heartburn, waiting those three days isn’t an ideal option.

Morrissey says instances like these aren’t always a fun decision. If the medication is relatively inexpensive and the patient can’t pay, Morrissey says that Kilgore’s might cover it while the paperwork is in limbo. But he simply can’t do that for the type of medications that sometimes cost more than $1,000, and he then has to explain his situation to a distraught patient.

An ideal solution?

Formularies have been around for a while, but they’ve become more prevalent in the past five to seven years, Morrissey says. Before, fewer plans had them and they were relatively simple: one co-payment for generic drugs and another for brand-name ones. Now, he says, some plans have three and four tiers of co-payments and the situation gets more complex each year. Co-payments and deductibles have also gone up.

Ideally, Morrissey says, pharmacists would be in control of “therapeutic substitutions,” or substituting a drug with another in the same class without having to go through a physician. This would reduce the hassle for him and for patients who simply want their medication.

Insurance companies providing leeway when their formularies change would also help, he says. If, at the beginning of the year, a patient wants a refill on a prescription that was formerly covered, the insurance company could give a one-month grace period to allow the patient to get a new prescription from his or her doctor.

“That way, this person isn’t sitting in my pharmacy for 20 minutes or a half hour to get it figured out,” Morrissey says.

Brownfield stresses the need for better education about which drugs are covered. If insurance companies could better relay this information to patients and providers, that would help minimize the problem. “Every time you try to call one of their help lines, it can be frustrating,” he says. “They used to send lists (of drugs that are covered). By the time we got them, they were out of date.”

Another possible solution mentioned by politicians is universal health care. Proponents argue that a national plan would reduce confusion because there would be a sole provider of coverage. Citing the Medicare Part D frustrations as an example, Brownfield says he doesn’t think it would be realistic to implement a program that large because it would create a national formulary for a population with diverse medical needs.

“In theory it sounds good,” he says. “I just don’t think that would fit for everyone.”

Morrissey says that a national program might solve some of the industry’s problems, but he thinks that it would present a whole new set of problems, like longer waiting times for procedures like an MRI.

“Unfortunately, health care does boil down to money,” he says. “There’s a lot of problems with our system, and right now the price is astronomical, but we do have the best health care in the world.”


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