Oh Canada!

A co-worker was chatting with me today and we got around to talking about health insurance issues.  I described the situation with my medications and the bind Aetna is placing me in with respect to nonformulary medications.  Just to summarize: starting 1 January, the medication prescribed by my doctor will cost more than 3 times what it did in 2009; the option that is cheaper is a generic medication that my doctor has never prescribed.  Since this generic medication is a schedule 2 drug, the DEA mandates that i see the specialist once every 4 to 6 weeks.  The savings to Aetna are thereby wiped out.  The medication may cost them less but seeing a specialist 10 times more a year than before will not come cheaply.  (I've already detailed this issue in previous posts.)

So, he said to me: why not go to Canada?  You can get the medication preferred by your doctor for a fraction of the cost.  They even have a generic version available.  He suggested that maybe I could even just take a prescription from my doctor and get it filled in Canada. 

I told him i would research it.

My gut reaction is that there is surely a kink.  Why would a Canadian pharmacy honor a prescription from a US doctor?  Even if they would, surely this wouldn't be legal?

If it were doable and legal and only required a trip across the border, then why wouldn't more US citizens take advantage of the savings?  I know some elderly US citizens have actually gone to Canada for their meds.  Is it legal?  Is it possible?

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.

(Source)


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.

QRG6KP6GME5C

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!

(Logo source)

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Health insurance fairy tale

Once upon a time, in a kingdom far away, there lived a happy little group of people in a nice little village in a lovely setting.

(Photo Source: Flickr, Donna Cymek)

These people worked together in the community, each performing some role.  Some people were particularly skilled in one thing, other people possessed another set of skills.  They each earned a decent income working in this community and paid sums of money each month (let's call them premiums) into an account from which members of the community would draw in time of need, medically speaking.

One group was assigned to manage this account.  Over time, they saw that there was generally money left over, which they would pocket.  They liked having not just a salary for managing the account, but also having high profit margins.  Let's, just for the sake of convenience, call this group who manages these premiums for the health maintenance of the happy community: Aetna.

Aetna did a good job for many years; the people in the community were well-cared for and as long as they paid their premiums, had reasonably low expenses for the medical benefits they needed

The community was happy and prospered.

One day, Aetna found out that some people in the community were talking about having a central representative body govern over this health care account.  Aetna became angry.  On top of that, Aetna hadn't pocketed much money the last year.  In fact, they had to pay out more than was paid in (for the first time).  If you were to total all the years they made a profit it would balance out in their favor, but that's not how Aetna saw it.

(Photo Source:  Berlin 07: Angry Fish At The KaDeWe.)

So, angry Aetna decided, due to both concerns, to raise premiums on the community, making each member of the group pay significantly more for the health care account and benefits.  At the same time, they also decided to establish new rules and limitations on what the people of the community could do with the money from this account and how much they could take out.

The people of this once happy community were not pleased by these changes and asked Aetna to reconsider.  Aetna gave a few minor concessions, just to shut the people up, and continued on its merry way, pocketing large profits and rendering fewer services.


Did Aetna know that these actions served only to make people more serious about forming some sort of representative body to govern over the health care account?  Perhaps Aetna didn't really care: get as much money as possible as long as possible.

Meanwhile, some members of the once happy community were hit with hard times financially.  They cut corners and worked hard just to make ends meet.  The higher health care costs and lower benefits provided by Aetna really make things tough for these citizens.  For whatever reason, they had health issues that made them very much in need of medical care and medications  As it became harder and harder for these people to pay their medical bills, they became even more marginalized.  not only did they have medical conditions that affected their day to day lives, but now they were paying enormous sums just for what had once been considered standard care, rendering them now unable to live their lives as "normal" people.  Those people graced by good health went along their merry way; the people with health conditions scrimped and saved and struggled to make ends meet.  They knew of course, that some people who didn't happen to live in the community had no access to any health account whatsoever (not even under severe conditions) so they felt badly  about bemoaning their own state of affairs.

Aetna cared little for the people external to the community without health care or even those in the community who had medical conditions.  They apparently just felt that as long as they could stay profitable, they would continue to play the game, raising the stakes everywhere they could so that they milked the community as long as possible.

The End.

(Photo Source: Standard Rights Managed (RM) BE037954,  Illustrated Political Cartoon: Corporate Greed as Octopus Original caption: 6/27/1882 - Corporate greed octopus gobbles up freight for Great Railroad while unemployed handlers look on. Cartoon 1882. IMAGE: © Bettmann/CORBIS)

Raising health care costs: Researching options

What to do after you find out that your health insurance benefits will cost more and provide you less:

• Step one: Panic. Feel badly about panicking because after all you have insurance and a job which puts you in a pretty good position these days in relative terms. 
  
• Step two: Research, ad nauseum, how much more you will be spending.
• Step three: Panic as you realize that you will be paying the equivalent of a pretty pricey new car loan for the same benefits you had the previous year.
• Step four: Review your budget and see what costs you can trim. 
• Step five: Panic as you realize that you can trim a little here or there but it won't add up to the amount you will now have to shell out just to be medicated.
• Step six: Think about trading in the car for some cheap piece of junk?  Price pieces of junk and get depressed at the thought of having to drive one.
  
• Step seven: sink into a deep depression as the reality hits you that you will never have nice things; your health care costs will go up and up and you will be cutting corners and scrimping and saving forever.
• Step eight: talk to HR and see if they have any ideas.
• Step nine: Panic as you realize that they have no ideas and really just want you to go away; they don't understand what it's like to have rare disorders for which expensive medications are required.
• Step ten: Research what medications might work for your conditions that would be in category one or two.
  
• Step eleven: make appointments with your doctors.
• Step twelve: Look for jobs with higher salaries.
• Step thirteen: Fall into a sea of despair as you realize there isn't exactly a plethora of jobs and even if you got an offer for a good one, whose to say those health care benefits wouldn't also now be inadequate.
  
• Step fourteen: Review your budget again; isn't there any way to cut costs?
• Step fifteen: Panic.
  

The "Open Season" health care surprise

Many companies that offer health insurance to their employees have "Open Season" around this time: typically some window of weeks during November/December.

Open season is the time when the HR folks at a given company unveil the changes in benefits/cost to employees and allow them to consider what types of plans they will sign up for.   Many people have little in terms of options, but if you work for a big company, you probably can choose between a couple plans (with dental maybe or hmo versus non-HMO, maybe also a health care spending account?).

Ok, first of all, let me say upfront: I am going to bitch.  I am going to express my utter despair and sense of frustration.  That said: i know i am lucky to have any health care options (however ill-suited they may now be for me); there are people who are unemployed, self-employed, or employed by companies who offer nothing.  There are families who can't afford even basic care for their children.  I know this and I am not insensitive to their plight; our health care system is broken.  i wish i had a solution for them.

So, why am i starting another blog when the blogosphere is so over-crowded already?

I have a great job; the income is on the low end of competitive, but that was off-set with terrific benefits (including health insurance and sick leave etc--things very important if you like me, have some medical conditions.) So even when i was told that i might be able to get a job with higher earning potential, i stuck with my company.  Now, even though they still offer benefits likely better than most packages, i find myself facing a difficult future.  In these hard times, I am of course happy to have a job.  i never forget that.

Ok, so someone asked me yesterday: "You're telling me that a PhD with a good, stable, well-paying job with good health insurance won't be able to afford her medications?"

Yes. 

The succinct version of the story is as follows:  Aetna told the HR folks where I work that they were discontinuing their PPO plan we had; we now will have a POS (they say that means "Point of Service," but in my view it means "Piece of Sh...")  The big changes are in price and benefits.  Apparently this isn't just Aetna or my company.  Across the board, in response to rising costs and the health care debate, major insurance companies are hiking prices and changing benefits.  It's part of a trend.  This year, prices are higher and benefits have been trimmed; next year the hike will be more steep with even lower benefits.

Many people will not really feel the pinch this year.  Next year, the size of the pool of insured feeling the pnch will increase. 

In my case, it's not just a pinch.

In addition to a steep increase in monthly premiums, the copays will be higher, as will the deductible.  Ok, big deal.  That's not really the source of my financial pain.  My issue is with pharmacy benefits.   Again, trying to be succinct:  there are generally three or maybe four categories that insurance companies place medications in.  These categories determine how much the patients have to pay for their prescribed medications.  Category one, the cheapest, are of course the generic (that's what the insurance companies prefer people to take); next are what they call Formulary drugs (which means they are on a list of acceptable medications; insurees will pay probably double for these drugs when compared with generic prices.)  Non-formulary is category three:  these are drugs the insurance company really wishes insurees wouldn't take; they are often not available in generic form; they are often expensive; they are often not the standard meds most people take.  If there's a category four it's meds requiring special authorization or something like that.

I guess i am lucky.  I have been diagnosed with a number of rare conditions for which I am prescribed category 3 drugs.  I have tried other medications (that would be in category one or two), but the doctors have determined that the best drugs to treat the conditions in my case happen to be drugs without generics (at least not with generic versions available to consumers.)

So, in terms of cost: i will go from approximately $70 a month for prescriptions to $500. That's not even factoring in the increases in premiums, copays etc.

So, without going into specifics, I can't squeeze out an extra $470 from my budget.  I can't move somewhere cheaper because my home (purchased in Sept 2007) is worth less than i owe.  I am making the payments and hoping to get out from underneath it eventually, but i can't just move.   I already watch my expenses and pay off credit cards each month (I am not really very extravagant.)  i can't get a second job because, well, with a sleep disorder i am lucky if i have enough energy to do a full time job and maintain the household.  (and that's with my category three medication.)

So, i tried to find a supplemental pharmacy insurance that might, coupled with my current Aetna insurance, help with the increase in costs.  I found nothing that wasn't either exclusive to AARP members or Canadians.

With preexisting conditions, I can't switch to a new insurance company.

If another option were offered through my work where the costs were higher but the coverage was more like it was in 2009, i would take it in a heart beat, but that's not an option either.

So, basically, I have several rare conditions (oh and in late November I am scheduled to see a hematologist because the docs think i have yet another rare condition to add to the list) for which i take medications.  I take the medications in order to be able to function in my demanding job at levels that meet my bosses' expectations.  i know it sounds improbable.  believe me, there's not a day when i don't think: how could i have several rare disorders?  They must be linked in some systemic way--but unfortunately i didn't study medicine so all i can do is try to read medical journals and reports etc.  Most doctors don't really practice medicine in a systemic way.

If someone happens upon this blog who either has similar problems, please share your story;  if someone has ideas abut what people like me can do, please share them.

I am still exploring and researching and will post more as I have more information.