August 2014

Follow Your Doctor's Orders—But Don't Expect Us to Pay Attention to Him

If you your prescription provider only allows you a third of the pills the doctor has told you to take, should you take one pill every third day? Or should you take one pill a day for a month and then do without them for the next two months? Or should you cut them up in such a way that you can take a third of the full dose everyday?

About a half hour into a conversation with a fellow who serves as a mouthpiece for ExpressScripts, I found myself asking those questions. He replied that I should take them exactly as my physician had prescribed them. He tried to sound as if taking pills he wouldn’t let me have was an obvious and simple course of action.

During this extensive conversation, the representative of my “health care provider” also told me:

•That the prescription for which I had received a denial notice had never been received by ExpressScripts.

•That, yes, the prescription had been pre-approved, but that didn’t mean the prescription had been received.

•That if I wanted him to look for the prescription, I would have to wait on hold a listen to the same saccharine tune over and over, because he could only address my case while I was on hold. He could not do work that didn’t require my input and then call me back, because . . . well, the why was a bit cloudy.

•That, yes, the drug had been prescribed and pre-approved but that my doctor wanted me to have too much of it.

•That it didn’t matter that I had been told other things at other times.

•That I should not think his story world change, even though he had just changed his story about the prescription not having be prescribed or pre-approved. Or because his colleagues had given me other stories. ExpressScripts was committed to my health and didn’t treat its customers’ health lightly.

•That I shouldn’t doubt either the accuracy of his statements or the goodwill of his company just because they had wasted a great deal of my time and denied me a drug my doctor says I should have.

•That, yes, I should have my doctor waste more of his time pleading for the drug if I wanted to take the drug he had prescribed.

•That I shouldn’t should so hostile.

After that, I called my doctor a couple times, and he and his staff did, indeed, waste more of their time begging ExpressScripts to let me have the drug. We reached a point where I did receive the full dose, but only as two separate prescriptions at different dosages, and I had to produce paper coupons to get one of them. Then another month went by, and, whatever they had done in the past, now they would not let me refill the prescription until two week after I had run out of it again. Then we reached an accommodation whereby I got a month’s supply of the drug at the price I am to pay for drugs according the stated rules of my plan every third month. During each of the two off months I would have to pay more than a thousand dollars for the drug. Things went on like that until a test showed I should not take the particular drug anymore.

Only that last decision was about my health. Everything else was about money. The guy who fronted for ExpressScripts on the phone told me that his company does not care about money—or that, if they do, they make money by fulfilling prescriptions, not by denying them. I tried to reconcile that story with the newspaper reports that came out a couple days later about the company’s deciding to reject a whole class of prescriptions—one’s involving compounding pharmacies—because they cost too much, but I didn’t manage to square that circle. I know that I was promised healthcare in retirement in return for years of labor, but how much healthcare I get seems to be in the hands of people whose motivations do not include looking after my welfare.

I mention this colloquy the ExpressScripts flak as more evidence that our health care system is in a shambles and that neither the defenders nor the opponents of the Affordable Care Act are paying any attention to the real problems. The insurance companies—and I include ExpressScripts in that group—have no interest in the welfare of the patient. They make money by
not paying claims. My former employer, the State of Illinois, decides which of these companies to employ not on the basis of how well they further my health and welfare but—let's just say on the same basis it made the decisions that left its pension funds depleted and its former governors in jail.

I am not for having the government—certainly not the state government—take over the health care system. They do a rotten job running some parts of it, though an excellent job managing others. I am for a single, governmental payer. Private providers would complete on the basis of health results and patient satisfaction, not on widening the spread between what they pay for drugs and actual cost of the drugs they deliver. Patients would be better off, and people like the man I talked to on the phone would be able to do respectable work instead of shooting people who are being cheated through the grease.