A Taste of Failure

“Not until after dinner,” my mother declared as I attempted to navigate the kitchen. I wanted to reach into the cookie jar and sneak out one or two round pieces of sugar goodness before supper. Mom kind of expected my brother to try this sort of thing but I was usually the good one who did the right thing. But on this day, the lure of a chocolate chip cookie before supper was too great for a young red-headed kid.

Since the stealth mode failed me, I tried to lobby my way to get what I wanted. I didn’t see the harm in having a cookie before supper. But the harder I tried to plead my case, the more my mother refused my request. In the end I was eating my broccoli and chicken at dinner sans cookie. My mother is one of the kindest persons you will ever have the fortune to meet, but she’s still a mom. And raising two boys means you earn your stripes quickly as a parent.

I thought about that day trying to argue my way to a pre-dinner cookie and my inevitable failure when I reflected on an exchange I had with an insurance company just yesterday at work. Oddly enough, that feeling of failure brought me back to those days gone by in the kitchen with my brother—even though this work situation was completely different.

Sunday was a crazy day for me and the technicians unfortunate enough to have work duty with me. We were busy from the opening bell and the problems came early and often. But it was a call from a regular patient with a very urgent problem that turned out to be the most memorable part of my Sunday shift.

The patient on the phone explained to me that she had just been released from the hospital. She suffered from a nasty bleeding ulcer and she needed the proton pump inhibitor (PPI) they had started her on in the hospital. It was working and helping her ulcer but she was completely out of medication and didn’t want to risk a complication by abruptly stopping treatment.

Enter the insurance company. Express Scripts of course would not justify paying for the brand PPI her doctor prescribed without first getting a prior authorization. The generic and OTC alternative ESI preferred was already a known failed treatment option for this patient. She needed her medicine and couldn’t wait for any approval to be processed by ESI. It was Sunday and the doctor who prescribed the medication wasn’t available. But, there was a surgeon in the same department on call. So what is a pharmacist to do?

First, I thought to call the doctor on call. It was Sunday and the surgeon returning the page was less than pleased with being bothered. At first he asked about alternative therapies but eventually told me the patient would just have to pay for a few pills out of pocket and straighten this mess out later. The one point this physician made clear was the fact that he was NOT calling the insurance company on behalf of the patient. I was on my own at this point to try and solve this problem for the ulcer patient.

I was then ready to give up and cash out the claim and give my pre-scripted “I’m sorry but there is nothing we can do” speech to the patient. But I was angry and frustrated and I thought I’d give ESI a call myself. That was a big mistake.

After being transferred a minimum of five times, disconnected twice, and repeating this patient’s information and situation a half dozen times I got nowhere with the insurance company. ESI would not even review the claim in question because I was a pharmacist calling for the approval and not the prescriber. They said the patient will have to wait until at least Monday to get anything approved.

I argued, pleaded, and even scolded the ESI representatives on the phone. But in the end I couldn’t get the medication approved, even after 45 minutes on the phone. Dejected and defeated, I finally hung up the phone and went back to work.

I ended up simply forwarding this patient five days worth of medication at no charge to ensure there would be no break in her therapy. “We’ll have to straighten this mess out later with the insurance company,” I explained to the family members who came and picked up her medication. And that was the end of my Sunday ordeal.

But as my anger quickly subsided and I thought back on what had happened with this insurance claim on Sunday, I was saddened and frightened. I thought about how most of this complicated mess we call health care now has nothing to do with helping patients at all. It’s all about rules and money and insurance contracts. Patient care is an afterthought at best.

And then my thoughts turned towards the potential ESI/Medco merger. I couldn’t help but think that if this is how ESI treats patients now, what will things be like after the merger? The future of health care as we know it could change as a result of a few big insurance mergers. What power will patients and providers have to fight insurance companies if the health insurance industry grows even stronger through consolidation? It’s a definite risk to our ability to effectively treat patients and bill third party claims effectively.

The profession of pharmacy should be on watch. This Medco/ESI merger is a bad idea. I witnessed the complete disregard for patient care they are capable of yesterday at work. And it will only become more pronounced if this merger happens. ESI is already powerful enough to simply deny even reviewing a prescription claim for a critically ill patient simply because it happened to be a Sunday. What will be coming in the near future if Medco joins the fold?

So yes, I failed yesterday to get that ulcer medication approved. But my question to you today is this: why are so many key components of our health care system so disconnected from patient care? Why does a pharmacy have to be the ones to bail out a patient in need? The system failed this ulcer patient yesterday and I’m afraid it will continue to fail other patients in the future. ESI had no qualms about leaving this patient to fend for themselves, even if they didn’t have the money for the expensive treatment that was critical for their recovery.

I caught a glimpse of the future yesterday at work. I had a nice long taste of failure trying to help get one ESI claim paid. And I have a bad feeling about what things will be like if this ESI/Medco merger is completed. I can’t help but think that feeling of failure will become more and more familiar to me going forward. And just like when I was a kid, it isn’t a good feeling.