Medco Rant

[cabinetman]

And have those generics been tested? probably not.

Now that's a frightening thought.
.

[leehljp]

Not Medco or similar . . but Japanese "Customs": LOML is diabetic and has somewhat high BP. Getting balanced diabetic medicines and BP medicine has taken some doing, but she has - with the help of a good doctor in Memphis. A one of the medicines is made in Japan - but only for export. The doctors here don't use it, so we import it. Our pharmaceutical related organization ships her meds every three months - including my stomach acid medicine. (Aciphex)

Well in the past two week a few Japanese movie stars have been found with some drugs including an excess of prescription drugs. A crack down has come into effect and medicines are checked closely. For us and anyone for that matter - only one month's prescription at a time is allowed in. (The Michael Jackson case didn't help). We spent the day talking with "customs" and having our legal office doing the same. They gave LOML and me a month's worth of our meds and disposed of the rest, and two of the meds were made in Japan. Mine is not absolutely necessary as I can take mine every other day and be fine, but LOML can't.

One reason that Japanese doctors don't use meds like Glucophage or similar is that Diabetics in Japan are treated based on the fact that they are alcoholics. LOML is a teetotaler and always has been. I can't tell you how many doctors have told her to quit drinking! When told repeatedly that she doesn't drink, several of the doctors over the past 14 years have said: Well, if she "doesn't drink", tell her to stop drinking anyway!" Hard to believe people can be so smart and dumb at the same time!

[cgallery]

One reason that Japanese doctors don't use meds like Glucophage or similar is that Diabetics in Japan are treated based on the fact that they are alcoholics. LOML is a teetotaler and always has been. I can't tell you how many doctors have told her to quit drinking! When told repeatedly that she doesn't drink, several of the doctors over the past 14 years have said: Well, if doesn't drink, tell her to stop drinking anyway!" Hard to believe people can be so smart and dumb at the same time!

OMG, now that is frightening!

[BigguyZ]

.



And have those generics been tested? probably not.

Sorry, but you're 100% incorrect there. All generics dispensed are regulated by the FDA. And generics are only reccomended by PBMs if they're AB rated generics- per the FDA.

Keep in mind that there are many BRAND name drugs that are manufactured in other countries. It's not just generics. I think when the gov't reccomends not buying drugs from other countries, they mean drugs sold in other countries. There are a lot of counterfeit drugs being sold overseas. Drugs manufactured and distributed in the US via regulated channels (Pharmacies, Dr offices, Hospitals) are fine.

[dkerfoot]

Now you got me started. Warning - rant ahead....

This may sound odd, but I think the biggest problem is that far too many Americans are over-insured!

Why have insurance for standard maintenance procedures? You probably don't pay for the extended warranty on electronics and I bet you don't pay for insurance to cover oil and filter changes on your car.

Having my house insured against fire makes sense because I can't reasonably budget to cover the cost of a total loss. But should I pay insurance to cover if my dishwasher stops working? Obviously, in the long run, it will cost me much more than just replacing or repairing my appliances as they fail over time.

Yet we pay to "insure" our eye exams and physicals... What kind of sense does that make to add these additional layers of waste and profit making? Think about all the people who are making a living off of that process. Can it really possibly cost less than if it was just you paying the Dr. for the service?

I have high deductable insurance and a Health Care Spending Account. The first $4700 or so of my families medical expenses come out of my pocket. This makes me a wise consumer, because it is my money! When a Dr wanted to x-ray my Son's broken toe, I asked how the results of the x-ray would affect treatment. He had no good answer, so the x-ray was skipped.

If one of us gets hit by a truck or comes down with a serious disease, the insurance kicks in after the $4700 is spent and covers 100%. So far though, every year we have kept our expenses well below that level and the money that isn't spent rolls over into a tax-free investment account.

Sadly, one of the "benefits" I gain is that all expenses are still submitted through the insurance company, so I am charged the much lower "insured" rate. I don't know if it is good theology, but I am pretty sure that Doctors and hospitals who charge a higher rate to uninsured patients (nearly all of them do) are headed straight for ****. This is just plain wrong and MUST be made illegal.

My wife has occasional migraine headaches. She also has regular headaches sometimes. Back when her insurance made Imatrix almost free, she went through four times as many of the pills as she does now that the full cost is known. It is funny how well Ibuprofen works when the alternative costs you $20 each... When the Ibuprofin doesn't work, we are thankful for and gladly pay the extra for the Imatrix.

My FIL's dermatologist snips off a dozen "suspicious" bits of skin each and every year. Not one has ever been shown to be cancerous. He knows darn well the Dr is padding his account, but it doesn't cost him a thing so he keeps going. You can bet if he was paying $1000 per visit to have these procedures done, he'd be asking a lot of hard questions.

If standard, non-lifesaving health care actually cost all Americans more, we would be much better consumers of it. Once something becomes free, or close to it, it loses value.

[parnelli]

Sorry, but you're 100% incorrect there. All generics dispensed are regulated by the FDA. And generics are only reccomended by PBMs if they're AB rated generics- per the FDA.

Keep in mind that there are many BRAND name drugs that are manufactured in other countries. It's not just generics. I think when the gov't reccomends not buying drugs from other countries, they mean drugs sold in other countries. There are a lot of counterfeit drugs being sold overseas. Drugs manufactured and distributed in the US via regulated channels (Pharmacies, Dr offices, Hospitals) are fine.

I'll agree that the factories are FDA inspected- so things should be fine. Though outside of GSK having lots of problems at a factory in Puerto Rico a few years ago- India is having more than it's fair share of problems.

As for AB ratings- kinda yes and no too. Everyone pushes generics because costs are lower and profit margins higher. Is your cholesterol going to be the same on high dose Lipitor as it would on lovastatin? Nope, but Medco has it's reps go to offices with a list- "Here are all your patients on xyz- would you consent to switching them to abc?

It's not just pharmacists that get 'spiffed' for filling generics- depending on the insurance company docs can get pretty large 'bonuses' for using say 75% generics across the board. Also- $4 programs have been a huge winfall for the insurers. Take the same premium- and then get patients to use the $4 generics, who are willing to, because it's less than a copay and suddenly the insurer is paying out nothing.

[LCHIEN]

...
As for AB ratings- kinda yes and no too. Everyone pushes generics because costs are lower and profit margins higher. Is your cholesterol going to be the same on high dose Lipitor as it would on lovastatin? Nope, but Medco has it's reps go to offices with a list- "Here are all your patients on xyz- would you consent to switching them to abc?

...

replace Medco with TelDrug. My doc said no. Teldrug said, then, we're not filling this prescription. I'm going to have to pay for a months Lipitor on my own nickel, or should I say $99.99 worth... until we get on the a drug plan, happen to be switching right now. That makes arguing worthless. Then see whats happening.

[docrowan]

This may sound odd, but I think the biggest problem is that far too many Americans are over-insured!

Why have insurance for standard maintenance procedures? You probably don't pay for the extended warranty on electronics and I bet you don't pay for insurance to cover oil and filter changes on your car.

Having my house insured against fire makes sense because I can't reasonably budget to cover the cost of a total loss. But should I pay insurance to cover if my dishwasher stops working? Obviously, in the long run, it will cost me much more than just replacing or repairing my appliances as they fail over time.

Yet we pay to "insure" our eye exams and physicals... What kind of sense does that make to add these additional layers of waste and profit making? Think about all the people who are making a living off of that process. Can it really possibly cost less than if it was just you paying the Dr. for the service?

I have high deductable insurance and a Health Care Spending Account. The first $4700 or so of my families medical expenses come out of my pocket. This makes me a wise consumer, because it is my money! When a Dr wanted to x-ray my Son's broken toe, I asked how the results of the x-ray would affect treatment. He had no good answer, so the x-ray was skipped.

If one of us gets hit by a truck or comes down with a serious disease, the insurance kicks in after the $4700 is spent and covers 100%. So far though, every year we have kept our expenses well below that level and the money that isn't spent rolls over into a tax-free investment account.

Sadly, one of the "benefits" I gain is that all expenses are still submitted through the insurance company, so I am charged the much lower "insured" rate. I don't know if it is good theology, but I am pretty sure that Doctors and hospitals who charge a higher rate to uninsured patients (nearly all of them do) are headed straight for ****. This is just plain wrong and MUST be made illegal.

My wife has occasional migraine headaches. She also has regular headaches sometimes. Back when her insurance made Imatrix almost free, she went through four times as many of the pills as she does now that the full cost is known. It is funny how well Ibuprofen works when the alternative costs you $20 each... When the Ibuprofin doesn't work, we are thankful for and gladly pay the extra for the Imatrix.

My FIL's dermatologist snips off a dozen "suspicious" bits of skin each and every year. Not one has ever been shown to be cancerous. He knows darn well the Dr is padding his account, but it doesn't cost him a thing so he keeps going. You can bet if he was paying $1000 per visit to have these procedures done, he'd be asking a lot of hard questions.

If standard, non-lifesaving health care actually cost all Americans more, we would be much better consumers of it. Once something becomes free, or close to it, it loses value.

Amen, brother. I've never had dental insurance. I make decisions on my dental care based on how it fits into our quality of life, just as I do with housing repair, cars, vacation, etc. I would like to go to the dentist twice a year for a cleaning and checkup, but my teeth are in good shape, they never find any real problems, and I've opted to save that $150 to go towards things that my family values more highly. However, when my wife had to have a root canal after her first pregnancy, you betcha, it's gotta be done.

The biggest problem is the vast majority of Americans have health insurance so the system is set up to cater to the needs of the insurance company, not the needs of the consumer. Try asking the average doctor how much a procedure will cost - complete and total. If it's anything beyond a very minor office visit, he or she won't have a clue. Call a mechanic or a roofer and ask how much a repair will cost and you will get a much better answer. If you don't you will hang up and call the next guy in the phone book.

[parnelli]

replace Medco with TelDrug. My doc said no. Teldrug said, then, we're not filling this prescription. I'm going to have to pay for a months Lipitor on my own nickel, or should I say $99.99 worth... until we get on the a drug plan, happen to be switching right now. That makes arguing worthless. Then see whats happening.

Lipitor has savings cards that should knock off something like 30 bucks off of that. Also with cash prices- call around! You'd be shocked at how much prices will vary.

[cabinetman]

Try asking the average doctor how much a procedure will cost - complete and total. If it's anything beyond a very minor office visit, he or she won't have a clue. Call a mechanic or a roofer and ask how much a repair will cost and you will get a much better answer. If you don't you will hang up and call the next guy in the phone book.

That is the truth. Leave it to coding.
.

[sparkeyjames]

I'm changing insurance companies Sept 1. It's not going to be resolved before then. Sigh.
Is this a taste of socialized medicine?

No it's a taste of greed based medicine. Don't confuse the two.
In greed based medicine the Insurance company wants to keep
as much of the premiums paid to it as it possibly can. Share holders love them
for this. To them the bottom line is more important than providing quality medical
care to you.

In socialized medicine you would have had your pills by now because everyone would be footing the bill.

[dkerfoot]

No it's a taste of greed based medicine. Don't confuse the two.
In greed based medicine the Insurance company wants to keep
as much of the premiums paid to it as it possibly can. Share holders love them
for this. To them the bottom line is more important than providing quality medical
care to you.

In socialized medicine you would have had your pills by now because everyone would be footing the bill.

This is steering towards the political, but I suggest to anyone who really wants the government running health care to ask a Veteran how much they enjoyed the military medical system. Alternatively, imagine you are at the DMV getting your drivers license renewed - while bleeding...

[chopnhack]

Long boring info ahead:

As for the pharmacist- years ago I'd readily agree that they had your best interest in mind and nothing else- but lets be honest- everything is a business. The pharmacist does sometimes get a bonus for getting people to switch to generics (higher profit margin) and they typically are ranked by generic usage by corporate- a little peer pressure. While cost is important- it's rarely the only important factor to consider.

And yes- many of the generics come from India from companies like Dr. Reddy's etc. Even at $4, WalMart's making money on those prescriptions.

I can tell you from the inside, Parnelli, that the $5 per week more that we get as an incentive to keep our generic margins over 85% is really not an incentive at all. Myself and several of my colleagues have discussed this at length and we simply won't chase corporate's balls through the hoops...#1 its not worth it and more importantly, we are patients too....do you really think any of us could have a clear conscience if we dont actually practice what we preach? we get sick, we have families that require care as well. do you think we have two playbooks to go by? one for the public and one for ourselves? I have served the same community for over 10 years and I am well followed and trusted. There is nothing more important to me than that....not even the money. When it comes time to make the choice between money and doing the right thing, the path will be clear....my a$$ walking out the door. And if your an RPh, I should say the same thing should be in your head and if its not, recall the oath you took upon graduation.

As for prior authorizations.......we dislike them as much as your doctors office does. From the operations side of things they are an unwelcome interruption to the smooth flow of pharmacy. Let me explain - you come in with a prescription for generic elavil, an old cheap medicine ...your insurer has no problem paying for it...we process your claim and it adjudicates in just a few minutes...we have time to fill and check the prescription and review your medication profile...after we finish filling the prescription we may even have time to discuss with you the medication and any concerns you may have. That is the routine I like

Now the rx needing a P.A. - you bring in a medication that is not covered under your insurance without a P.A. - we process the claim, it rejects. Many times the rejection does not clearly state what the problem is. Now someone has to call the third party processor to determine what the problem is with the prescription. We are put on hold or have to go through a number of prompts to speak with a representative. Sometimes we can get an answer at this point, other times we are transferred to the actual insurance company to clarify. Have you ever called your insurance company? After we finally do get an answer you have probably have been waiting for 15-20 minutes and have still not received any medication and are probably wondering what is taking so long. We then come to explain to you that your medication is not covered without a prior authorization....at this point most customers stop listening after the "your medication is not covered" part .... that not withstanding we will try to explain further that we will contact the doctor to try and get that PA done for you so that you can receive what the doctor wants you to have. We then fax the information over to the doctors office.
From this point on, I can only conjecture as to what occurs at the doctors office...but from the bits and pieces I have received over the years, in the better run offices the fax will be received and reviewed same day by office staff and then routed to the person who does PA requests, typically the office manager or billing specialist. They will call the insurer and ask for the forms to be faxed to begin the review process (PA). The insurer will then fax the info +1-2 days. The office manager will fill out what they can and put it on the doctors desk for review. The doctor may see the info that day or the next +1-2 days. After the doctor fills out the info the office manager will get it back and fax it to the insurer +1-2 days. The insurer will either approve or deny the claim +1-2 days. I have had this whole process take as little as 1 day, but that was only one time :[ In a poorly run office just multiply the above by about 4. And to boot most of the times no one thinks to contact the pharmacy to inform them that the authorization was approved, so we are left in the dark (many times).

Just remember with insurance, there are more hands in the pot. With more people and interactions come more complexity and more time to take care of something as simple as providing you with a medication. Of course if you walk in and just pay for it yourself it would much more expensive, but it would be much quicker. And that is the trade off involved.

I hope you find this information informative.

[billwmeyer]

Chopnhack,
Great comments! I love to here from professionals in the field, and it does sound like you are a true professional. We never know what happens on the inside. Thank you.

Bill

[Jim1]

Chopnhack,

You've done a very good job explaining how the process works. I've been practicing for 34 years. I believe this entire situation is almost entirely about the money.....not the patient's or mine, but the insurance company's (or their clients). Most of my patients do understand that there is nothing that I like better than to get their medicine to them as efficiently as possible. In so many ways we are able to provide better medicines, oversee drug interactions and to provide more and better information and services to our patients than ever before. Unfortunately dealing with 3rd party payors can consume tremendous amounts of time and cause endless agravation for both the pharmacy staff and our patients. The current scenario with prior authorazations has become an extreme burden for our profession and has misdirected time and effort which we could provide to our patients.......That said, I've enjoyed serving my patients and continue to do so.

Jim