Wednesday, November 18, 2009

A conversation with Aetna

So, this morning, an Aetna rep was available to talk with employees at my job about the changes to our health care options for the next calendar year.  Let's, just for convenience, call the representative: Mr. Aetna.

Mr. Aetna is sitting at a desk behind a computer and some stacks of pamphlets.  I sat down in the chair next to him and told him that i had some very specific questions about the pharmacy benefits that would be part of the new Aetna's POS plan.  I indicated that i had some medical conditions and that my physicians had prescribed me medications for these conditions that happened to be nonformulary.  With the changes in place in the POS plan, my pharmacy costs would go from about $70 a month to about $300.  I told him that while this was a significant jump in the expense and any raise i may get will not cover it, my biggest concern was that in future years the coverage for nonformulary medications would only decrease further.  I pointed to the phasing out of coverage for out-of network doctors and asked if the same would be true for nonformularly medications.

Mr. Aetna replied with a smarmy little smirk that he didn't have a crystal ball.


So, with that unsatisfactory response, i took the conversation in a slightly different direction.

I told Mr. Aetna that I had been to see my neurologist (sadly only one of the specialists i see) and had told him that I wanted to ask about generic options due to the major increase in pharmacy costs that i would face starting 1 January. I told Mr. Aetna how my doctor responded.  The doctor reviewed my file and said: you've been on this medication for 3 years; we've tried other medications and they didn't work; what is it that is on Aetna's formulary list?"  When i told him, his reply was that he had never prescribed the drug i was asking about to a patient with my condition ever.   He said that we could try it out but that i would have to agree to check my blood pressure regularly and also increase my number of appointments.  This formulary medication was (a) a Schedule 2 drug, strictly controlled by DEA (hence the requirement for monitoring appointments), and (b) had a very high incidence of causing hypertension, palpitations, and also addiction (among actually a whole host of side effects).  The doctor then said if he judged this formularly drug to be a poor choice for me after this trial period, that we would return to what we know works (the nonformulary medication i have been taking for 3 years.)  He added that i would then probably have a good case to make to the insurance company because i would have tried everything available in generic; with the doctor stating that none of the formualry medications worked, i would have a better chance of having the insurance company grant an exception.

So, i told Mr Aetna this story and asked about the process of possibly getting an exception on such grounds.

Mr. Aetna leaned back and smugly stated that there are no exceptions granted.

So, i explained that the reason i came to see him was because i wanted to talk to a real person (and not have to deal with phone menus and being transferred.)  I asked him the following question:

Why would the judgment of my doctor be superseded by a list of formulary medications decided upon by some committee?  Are there even medical doctors on the committee?

Mr Aetna told me that there are doctors on the committee.  Furthermore he stated that Aetna is not telling me what to take.  I can still take the drug recommended by my doctor.  There's just "cost sharing" now.   (So whether i spend $10 a month versus over $200, the choice is mine. Oh and that's in addition to my monthly premiums, of course.)

Mr. Aetna then tells me that his situation is not a rose garden (not his words, in fact he said he was not telling me what he was about to tell me to make me feel sorry for him.)  He told me that through Aetna the only health care plan available was one that involved a $2,800 deductible.

I told him i thought that was a horrible plan and asked if he had any other options (to which he replied no.)  I told him that there was a sad irony that Aetna, a health insurance company, valued health care so little that they would only offer one plan (and not even a good one) to their own employees. 

Mr. Aetna explained that it wasn't a bad plan at all; it reflected Aetna's view is that it's silly that people expect to pay more for a haircut than a trip to the cardiologist.  He then told me that they have excellent wellness benefits and said something about being paid little bonuses for every X number of miles logged on some piece of exercise equipment.  (Just as an aside: Mr. Aetna was no Mr. Atlas...) (Photo source)

So, i came back to the committee issue and asked if there was truly no means by which I could present my situation to a committee or whatever.  Mr. Aetna shook his head (with that smarmy smirk, of course.)  He told me that they were a business and had a bottom line they had to look out for and the realities of the economy play a role here.  Aetna needs to make a profit.

So, i took a new line of reasoning and pointed out that Aetna may, in the long run, not even save money by making me take the formulary medication instead of the one recommended by my doctor.  (To which he again reminded me that no one at Aetna is selecting which medication i take. It's my choice.)   I continued with the discussion:  If i have to see a specialist 10 times more (approximately) a year than i otherwise would have had to (if i stayed on the nonformulary medication) that adds up.  I pay $25 per visit but how much does Aetna pay?  Over the course of the year, will they not pay out as much for the extra doctor visits as they would for the nonformulary?  And then i mentioned the fact that my resting heart rate is now significantly above the healthy zone (i started my trial on the formulary drug last Friday and i have been, as my doctor required, taking my blood pressure regularly; while my blood pressure is doing fine,. my heart rate is not.)  Any long term health issues that result from taking this formulary medication that would not have happened if i stayed on the original medication would also be added expense. 

I asked Mr. Aetna if there really was no committee who might look at this case and make an exception (even if their reason behind doing so was purely profit driven)?

Mr. Aetna said that it was unlikely.  He mentioned that he knew of one time that a drug moved from nonformulary to formulary because it was clearly the best medication for a particular condition.  But the difference between that case and mine is that in that case, it was not only a widely prescribed drug but also a common condition.  My hand of cards includes some pretty rare medical issues.

In closing, Mr Aetna asked if i had a business card.  He asked what the nonformulary medication was that i had been taking and what the dose was.  he said he would look into it and get back to me.  but he told me not to hold my breath.

But keep in mind: Aetna is not deciding for me what medication to take.  They are just making sure i pay my share of the cost OR choose a cheaper drug if i can't afford my share.

Here's a nice little blurb from Aetna's website about their mission:

um yeah.  Based on my fun little chat with smarmy Mr Aetna, their mission has changed.  They now just want to make money.

High quality health care has now left the building.


Tuesday, November 17, 2009

When your insurance company makes medical decisions for you...

Ok, so here's the scenario... wait, let's make it generic (oooh there's that word again)

Patient X has medical condition Y.  Doctor A prescribes medication P to patient X because it's the medication best suited for condition Y.  Medication P is not available in generic form because it is kind of new and the company that makes it has managed to hold onto the patent (wait, the military has access to a generic form... but it is not available to consumers...).  Patient X takes this medication successfully for several years.  Patient X's medical condition is ameliorated and their quality of life is significantly higher than it was without medication P.

Along comes Aetna, and they decide that this happy little scene is too expensive. 

Patient X goes to doctor A and explains that prescription benefits in Aetna's plan are changing and will severely impact patient X's ability to afford health care.  Doctor A reviews the patient's medical file and says to patient X:

"Ok, so we tried drug R (available in generic) and that didn't work for you.  How many years have you been taking medication P?"

"3 years," says patient X.

"And what is it that Aetna wants you to take instead?' asks doctor A.

"Drug D, which is available in generic," answers the patient.

Doctor Y scratches his chin and reviews the information about drug D in his PDA-thing.  It turns out that he has never prescribed drug D for patients with condition Y.  He reviewed the patient's medical file.

"Well, i am somewhat hesitant to go from a medication that we know works to a medication that hasn't been widely prescribed for this condition in decades," says the doctor to the patient.

Patient X is flustered: "My monthly prescription costs will more than quadruple if I stick with medication P, which is considered 'nonformulary.'  And I fear it will be worse next year because trends suggest that nonformulary drugs will cost patients more and more each year until they are phased out (in terms of coverage) altogether.  I don't want you to prescribe a medicaiton that you have concerns about, but couldn't i try it just to see if it works?"

Doctor Y can see how concerned the patient is.  "This medication is somewhat different than what you've been taking.  It can't be mail ordered.  It's what they call 'Schedule 2,' which means it is highly regulated (by the DEA).  You will have to see me once every four to six weeks for me to check how you're doing.  You will need to take your blood pressure regularly.  If you have heart palpitations, high blood pressure, or any unusual side effects, you will need to let me know immediately.  I will give you a list of what to look for.  What you had been taking was a 'Schedule 4 medication' so this will be a different experience for you. But we can give it a shot.  If i judge that it's not the appropriate medication for you after this trial period, i will put you back on medication P, though."

"I understand," said the patient, carefully considering what the doctor just said.  The patient was puzzled because it seemed as thought the savings accrued by Aetna by having this generic drug prescribed as opposed to the nonformulary drug would be offset by the new requirement to see this specialist about once a month (with medication P the doctor checked on the patient once or twice a year.) 

The moral of the story is Aetna knows best.  The powers that be at Aetna are determining how medical conditions should be treated.  To hell with medical degrees.  After all, doctors don't know best, Aetna does!

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