Friday, August 17, 2007

Who's responsible for that prescription denial? If an MD has trouble finding out and is insulted in the process, what's a layperson to do?

I pity non-medical laypeople trying to navigate the mess that is called "the healthcare system." I've just had a most spectacular and bizarre encounter myself. The left hand does not know what the right hand is doing, which does not know what the foot is doing ... and the foot despises the body it's supposed to support for good measure.

Over the past few years, I've put on extra pounds. Way too many. My BMI has climbed to unhealthy proportions and I hit the big five-oh in age recently. After using sheer willpower to diet and exercise to drive my weight down 15 lbs. in a month, I had my blood work checked and parameters are decent. However, I need to repeat the weight reduction accomplishment a few more times over before I am back at a desirable BMI. It is not easy.

My personal physician (yes, doctors go to doctors) prescribed Meridia 10 mg daily, an Abbott drug in the Serotonin Reuptake Inhibitor (SSRI) class, and that's where this bizarre encounter with the "non-system" began.

The active ingredient in MERIDIA, sibutramine, works in the area of the brain that signals the sense of fullness (satiety). Meridia does not suppress appetite, which is your signal to start eating.

Meridia blocks the re-uptake of the brain chemicals (serotonin and norepinephrine) which help regulate the sense of fullness. Fullness is your signal to stop eating. Having a sense of fullness, or satiety, means you may feel satisfied with less food.

When I went to my neighborhood pharmacy a.k.a. megastore, I was told my health plan did not cover this medication. I possess a BC/BS PPO and Medco card through my employer, a university. The cost of a month's supply of the medication was approximately $160. The pharmacist suggested I contact Medco to find out why Meridia was not covered.

I did, which started a string of phone calls ending in my being seriously insulted by a service rep at Medco! The account (best as I can recall from memory, as things got convoluted) is as follows:

A Medco representative told me Medco is only a contractor and plan administrator to "my insurer" and does not make such decisions. However, the rep did not know who did.

I next contacted BC/BS. Their rep told me they only covered medical care and not medications, and suggested I call Medco. When I mentioned Medco told me they did not make such decisions, the BC/BS rep had no suggestions.

I called Medco back. The Medco rep this time told me I could appeal the denial and was sending me an appeal form that I should mail back to - Medco. Now, I was really confused.

I inquired why Medco gets an appeal form for denial of coverage if Medco did not make the decision. The rep did not know. I asked for the name of a person at the organization where the form would go. Again, the rep did not know.

I finally called my university's benefits management contact, yet another contractor company (it seems everything is handled by third parties - just a little bit of administrative overhead there?), and that is where this already confusing matter took a very deep turn directly south.

The rep at the university's Benefits Management contractor said that he believed Medco was the responsible party. I informed him Medco said they were not.

In the first actually creative and industrious response from any of these organizations, the rep said he would get a Medco representative on the phone in conference call mode so we might get to the bottom of this.

We got to the bottom all right. The real bottom.

The Medco customer service rep that the University Benefits Management Rep conferenced in was a new individual, not the ones I had spoken to prior. This rep repeated that Medco was just a benefits manager and was not responsible for the denial.

I asked the university's Benefits Management contractor rep if he believed that was the case. He was as confused as I. The Medco rep said I needed to appeal.

I asked the Medco rep for the name or identity of a person or organization where the appeal form would go, so I could contact them directly, as I was a medical doctor with pharma experience as well and wanted to go direct to the source.

The Medco rep replied that "my title would not get me advantage in this matter" or words to that effect.

I again tried to explain that I wished to know exactly who made the appeals decision. The Medco rep started to become patronizing in tone, not letting me get a word in edgewise and calling me "Mr."

I reminded the Medco rep that I was a physician and wished to be addressed more formally, as "Dr." I don't often make this request of anyone, but I was starting to sense something odd here.

The Medco rep again referred to me as "Mr."

I said once again that I wished to be referred to as "Dr."

The Medco rep once again referred to me as "Mr."

I think we went through three cycles of that little skit.

At this point, getting rather angry from this deliberate insult, I asked the Medco rep rather pointedly if her refusal to call me "Dr." was an act of prejudice (my name gives away my religious identity). At that point, the Medco rep hurredly put a supervisor on the phone. I don't think she'd ever been called on such behavior in such un-PC (i.e., unashamedly direct) terms.

The supervisor rapidly answered my question, telling me the University itself was who needed to be contacted. I mentioned to the supervisor that the refusal to call me "Dr." even after I asked for this courtesy was quite disturbing, reflecting at the very least a very bad level of customer service. The supervisor offered agreement.

I emailed the University HR benefits director (finally, a principal, not a contractor!) As it turns out, the University covers drugs, and I was emailed back that "this class of drug is not covered" (I presumed that means the weight reduction class of drugs.) I emailed back a question as to why. I have not yet received a response - and I'm not even going to go there in this posting. (Discrimination against the obese?)

On the other hand, the extremely rude and deliberate refusal of a Medco Customer Service Representative to call me "Dr." even when I asked for this courtesy several times was unbelievable.

I can only wonder what types of attitudes this person held about physicians - and if the company's customer service management or higher shared a similar bias. I also cannot discount other cultural biases. Imagine if the situation occurred in reverse.

I was able to find out very quickly from the Internet and several phone calls to Medco Corporate that the customer service department at Medco reported to the VP of HR. I believe physicians need to start being far more direct and confrontational when they encounter attitudes like this.

In Roy Poses' post "Bling Bling, Political Correctness, and the Anechoic Effect" it was observed that:

In the post-modern academic world, everyone is afraid of saying anything that might be the least bit offensive. (See the web-site of the Foundation for Individual Rights in Education, or FIRE, for some amazing examples.)It seems that that even the most skeptical and iconoclastic health care bloggers may also be fearful of being too politically incorrect.

I agree. And pushback should not just occur after major scandals. After calling the VP's administrative assistant who said she would forward my complaint to the VP if I sent it via email, I passed along details of what occurred as I summarize here (my email was actually a bit more direct):

As former Director of Scientific Information Resources and The Merck Index at Merck & Co. [note - Medco was a Merck subsidiary until a few years ago - ed.], I am familiar with the pharma industry and customer service. I am also a writer for the Foundation for Integrity and Responsibility in Medicine (FIRM) ... The interaction I had this morning (appx. 11:40 AM EST) with one of your customer service reps was so profoundly disturbing I feel you should be aware.

... your service rep was patronizing, would not let me get a word in to clarify my questions, but those were minor issues. When the customer service rep referred to me as "Mr. " I informed her I was an MD and wanted to be addressed as "doctor." The rep deliberately and repeatedly called me "Mr." after being told several times I wished to be addressed more formally. When I expressed my outrage, a supervisor was put on who did help answer my question about my medication coverage. The customer service rep sounded like a minority.

My question to you is: Was this an issue of your customer service rep disrespecting a man of European heritage? Was it religious prejudice, as my name is quite revealing in that regard? Or did it reflect a bias against physicians? Any of these would be a serious matter. I would really like to know why your rep refused to address me formally as I repeatedly requested.

Unsurprisingly, I have not heard back from the Medco VP of HR. I do not expect to. Medco has certainly had more serious fish to fry. Perhaps he will give his service reps some "sensitivity training" - towards physicians.

Finally, I observe that I am a physician and former corporate manager who had the greatest of trouble and frustration trying to navigate the morass of tangled third-parties-for-everything we call a "health care system" over a simple single non life-threatening prescription. I was insulted for my efforts by a pharmacy benefits management company just for good measure.

I can only imagine what Joe and Mary Citizen have to put up with.

(And, I've shelled out the money for the medication, deciding this one was just not worth pursuing further.)

-- SS


Anonymous said...

*Doctor* (I don't want to enrage you any further): Welcome to our health care system. I'm not sure whether you've been shielded by your doctor or academic or corporate positions in the past, but as a person who needs chronic attention from my primary care doctor (who I love) who fights on my side (continuously - 15 years now) against insurers, pharmacies, PBMs, rude managed care organizations, etc., my experiences could top yours by a factor of many.

But now you know. I'm sorry. It sucks. Nobody deserves it. I enjoy your posts, struggle with weight gain as well, and feel your pain. My biggest hope is that MedIT someday makes our system more humane, which is a horrible thing to say. But an unjust system breeds people working within it who learn to be unjust.

InformaticsMD said...

Welcome to our health care system. I'm not sure whether you've been shielded by your doctor or academic or corporate positions in the past

No, as former Manager of Medical Programs including preventive and drug testing for a huge public transit agency back in the early 90's I've seen it all.

However, such an in-your-face insult during what I considered an innocuous interaction to get a name of someone to talk to really caught me by suprise. It was not as if I'd just told someone who'd crashed his train and killed passengers that their drug abuse test was positive (a task I've unfortunately had in the past).

Sometimes, however, nasty people pick on the wrong people. Now, if only all physicians would grow a pair regarding abuses from "managed care."

-- SS

Anonymous said...

If an MD has trouble finding out and is insulted in the process, what's a layperson to do?” I’m sure this type of article would certainly spark debate from the non-professional readers of your site.

You acknowledge that you can sympathize with Joe and Mary Citizen, who lack your standing, your education, and your knowledge about dealing with “the system.” Have you considered that many Joe’s and Mary’s must (1) try to accomplish this sort of task on their 15-minute coffee breaks; (2) may be dealing with a life-threatening condition; and (3) have no expert help (such as the prescribing physician) to offer advice or aid for navigating the maze.

I’m certain that the disrespect shown by the service rep was not only unwarranted, but was perpetrated BECAUSE SHE COULD. (IOW, it is doubtful that there was a doctor or even a bureaucratic expert on the other end of the line.) Imagine, if you will, the disrespect—even outright disdain—these mindless robots display to NON-professional “customers.”


Unknown said...

I am also a physician and I have experienced similar behavior. In fact, so has my staff and it is clearly getting a lot worse.

I am doing something about this and would appreciate comments. Could you take a look at and tell me what you think.

Unknown said...

Just one more comment. I think that patients and doctors need to work together to fix this mess. I do not thing this can be fixed any other way.

Anonymous said...

Although I sympathize with the difficulties you experienced, I have trouble getting excited about the fact that the rep didn't call you "Dr." So what?

Anonymous said...

Just think how much more effective government workers will be in sorting out this kind of mess. And more courteous, too.

Stella Baskomb

InformaticsMD said...

Anonymous said...

Although I sympathize with the difficulties you experienced, I have trouble getting excited about the fact that the rep didn't call you "Dr." So what?

Why don't you speculate?

Also, if the situation were reversed and I'd refused to call a minority physician "Dr." even when asked to do so, what do you think this would be called?

Finally, if this issue has to be explained to you, you clearly have no future in customer-service positions of any kind.

Anonymous said...

I have had the headache of dealing with Medco for over three years now and everytime I complain about the costs of my medications, I get basically told "you have to do mail order if you want a cheaper price".
I truly don't trust Medco. I have many concerns, one of which is am I really talking to a Pharmacist or am I talking to a Pharm Tech who might be representing himself as a Pharmacist.
At least when I go to my local pharmacy, I know when when I am talking to a Pharmacist.
My most recent problems with Medco have to do with the prescription called Byetta.
They charge you the maintanence price, even when you only have a new prescription for this medication and there are no refills on your script.
Medco's reasoning is the usual, it is the price set by your wife's employer.
I recently wrote to Medco, and of course got replies from the eCSR's.
My complaint was that Medco has not posted the FDA warning of October 16,2007 regarding a possible link between Byetta and pancreatitis.
Replies to me from Medco range from they are forwarding my complaint to the proper authorities or that a Pharmacist will call me and finally that a Pharmacist couldn't get in touch with me. And they want me to call them to talk to a Pharmacist.Could be that they don't have my phone number.
Wonder what the FDA would say if they knew that Medco wasn't posting there warning since Amylin agreed to put that warning in all new packaging.