Another Hand of Cards

I have mentioned how odd I found it that I had to carry four or five health insurance cards when I was an employee of the State of Illinois, considering that all the money comes out of the same pot. I spent a couple years with another kind of coverage, but now I am back with the State, and they have dealt me a new hard. There are four this time, instead of five, but that is only because retirees are not eligible for the Employee Assistance program, which provides things like “Anger Management” classes and drug rehab. Since I am no longer likely to snap on campus, the evidently don’t care if their medical insurance provider drives me to go postal or start asking my friends visiting Thailand to mail me some Valium.

It, of course, makes no sense for me to have so many different cards and card numbers. I won’t go into what they are all for again, but yesterday I had an experience that reminded me how kludgy our system is—and how the innovations that make American business (and American medicine, until we start paying for it) don’t seem to reach our system of charging and paying for medical care.

This fall I am not worried about Ebola, which I have essentially zero chance of encountering. I am worried about the flu. A quick look at the Centers for Disease control web site tells me that about 200,000 people are hospitalized as a result of the flu every year, and as many as 49,000 die of it. I also know that when I have had it, I have been very unhappy—and that every year I age I am more likely to move from the “very unhappy column” to the “in the hospital” column. So I get an annual flu shot. This year, since I had serious surgery not long ago and have had some respiratory problems, I decided to get a pneumonia shot, too.

So there I am, the model patient. I am not putting in an already over-burdened Emergency Room under still more strain after I have been inflected. I am not taking up time in a busy doctor’s office. I am getting my vaccinations for influenza and pneumonia in the simplest and most cost-effective way possible. In other words, I am at the counter in the back of a suburban Walgreens talking to a pharmacist.

Things go smoothly until she asks for my insurance card. First, we try my health insurance card. Then we try my prescription card. If they were treating my flu shot like other prescriptions, that would tell the pharmacist how much Express Scripts would pay, and thus how much she should charge me. But the flu shot, which may prevent my needing much more expensive medical care and prescriptions, is not covered so simply. After some research, she discovers that I have to pay myself, and then file for reimbursement.

Let’s fast forward to the present, when I have downloaded the Express Scripts claim form. I now have two pages of text, lines, and boxes, which I am to fill out with a pen. I will enter the information encoded on my various cards—the form, in fact, tells me “See your prescription drug ID card.” I also find that I have to go back to Walgreens to get the signature of a pharmacist and the numbers to fill the boxes under “NCPDP/NPI Required.” I trust that either I or the pharmacist will make a mistake somewhere, which will allow Express Scripts to send everything back to me and delay sending me the payment I am now owed. (Why don’t I call Express Scripts for help? Because I know form experience that they will lie to me until I become so nasty that they break down and look in my records—while keeping me on hold—and that even after they can not longer argue the facts, they will invoke policies I have no way of researching until I give up.) Paper, signatures, envelopes, stamps, bureaucrats: the way the State of Illinois and Express Script like to do things.

But back to the pharmacy counter. Our adventure dealing with the people obligated to pay for my health care now being at their normal dead end, I need to pay. No problem. Walgreens takes ApplePay, so all I have to you is wave my iPhone and touch my finger to its “home” button. Done. Walgreens have a rewards program, and I am part of it. No card now either: I just get my virtual card up on the iPhone screen, wave it over the scanner, and my points are in the system. All that’s left is the shots. The pharmacist gets the doses ready with lightning speed, meets me behind a screen already wearing rubber gloves and ready with alcohol swabs and Band-Aids, and in less than I minute I am immunized, wearing two Band-Aids I don’t really need, and on my way.

But I am still left wondering: we me make our commerce ever more efficient and the actual delivery of medical care wonderfully smooth, so why do we still choose to apply none of that knowledge and skill to paying for health care? And once again, I see that neither the proponents of “Obamacare” nor its impassioned opponents are talking about the real problems a patient encounters. (You can, however, find them described quite well in Kafka and Dickens.)

But enough of this. I have forms to fill out. Where’s my pen? I hope I still have some White Out, in case I made a mistake!

[Update: After having had me fill out the the forms and get the pharmacist's signature, ExpressScripts declined to pay for my flu shot. Since they knew what drug I wanted reimbursement for before asking for the form and the signature, I would ask, “Why not just say ‘No!’” But I know that is not how the game is played: They don't want meet notice how often they say “No!” They want me to give up and say “The the hell with it.” If I just give up, perhaps I won't notice how many claims they deny.]