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Posted on 1. April 2011

Wasteful Healthcare Regulations

By Kris McFalls

Wasteful spending is probably one of the biggest undisputed causes of increased healthcare costs. How best to control those costs without compromising patient care, however, is disputed quite vehemently by several invested parties. As a result, many in the healthcare industry continue to establish rules and regulations in an effort to control costs. But, in the end, some of these rules actually make healthcare more expensive for all.

Case in point: Recently, my doctor wanted to tweak one of my medications to see if we could maximize the outcome without raising the side effects and costs. Research has proven that the absorption rate using the injectable form of the drug is better than the same dose given orally. Therefore, before moving to a much more expensive drug, my doctor asked me to try the injectable form. The plan sounded reasonable and affordable to me. So, I called my local Safeway pharmacy and inquired about the drug. I was told it was covered and that it was cheap, but my insurance company still required the drug to be preauthorized before they could dispense it.

Armed with the drug formulary and insurance policy on my computer, I called the drug preauthorization phone number. I sat and listened while a very nice woman gave me erroneous information, quoted wrong policy information and pointed me in a misguided direction. After which, I politely redirected her attention to her company policy and pointed out the formulary where the drug could be found. At that point, realizing she was probably overmatched, she asked that I please hold. After enduring an eternity of “on-hold” music, she confirmed that my interpretation of the formulary was correct and that the drug’s total cost with the insurance discount was $10.50. That meant that after my copayment of $10 the total cost to my insurance company for a one-month supply was 50 cents. Regardless, because the medication was an injectable form, it still required preauthorization.

So, the stream of red tape continued. The necessary paperwork was faxed to my doctor who then had to take more time out of her day to answer questions, fill out the form and fax it back with office notes to back up her recommended treatment plan - all the while knowing that none of her time spent satisfying the insurance gods was reimbursable. Once satisfied that all the boxes were checked and the policy was followed, my insurance company faxed back their approval but again gave erroneous information, this time stating the drug had to be purchased using one of their two chosen specialty pharmacies.

In the interest of research, I did call one of the specialty pharmacies. It took them four days just to verify my insurance. The same process Safeway did in a matter of minutes. But there is one advantage to using the preferred specialty pharmacy; they would ship it to my doorstep over night. Surely, the cost of that was justifiable given it was an injectable drug, right? I don’t think so.

Ultimately, only an accounting firm can tell the insurance company how much money it wasted trying to save 50 cents or how much more it costs to use a specialty pharmacy for such a cheap drug. In the end, however, it occurred to me that I could be a small part of the solution to this problem of wasteful spending. I called Safeway back and offered to just pay cash. I didn’t get the insurance company price, but the cost was affordable and the headache caused by insurance regulations was curable.

Have you encountered unnecessary wasteful healthcare spending? What suggestions do you have that could help control the cost of healthcare?


Comments (2) -

Janet Kaye
9:25 AM on Friday, April 01, 2011

Bless you Kris...too bad it takes so much work to figure out the obvious!

Nynah Mason
1:19 AM on Saturday, October 06, 2012

Eliminate insurance companies.  The only thing they wish to ensure is that they make unconscionable profits.  I would personally be thrilled to give to Medicare the money I shell out to my insurance company.  I would also prefer that 15% profit the insurance companies are allowed to pocket go into the Medicare community pot to help provide coverage for everyone.  It's time for the US to catch up with the rest of the civilized world.

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