Spending dollars to save pennies

On another docs’ forum I haunt, there was a recent post about frustrations with trying to get a patient’s diabetes-medication prescription refilled. Patient routinely followed-up with an endocrinologist, who electronically maintained/updated scripts to avoid any lapses. That is, until the patient (also a physician) noticed there were no refills remaining, two weeks prior to depletion. It should have been a simple matter to rectify. The multiple reasons why this failed to be the case all turned out to be issues with the patient’s healthcare-insurer, which in turns cited pharmacy’s failure to send prior authorization to the endo, endo failure to fill out the auth, endo failure to send current bloodwork results to the insurer, insurer finding fault with the bloodwork itself, wrong form(s) having been used, form not having been sent/received, insurer maintaining that the meds were not on the verge of running out, etc. Needless to say, each of these excuses turned out to be completely wrong. That is, the right forms had been sent (and were subsequently located), the bloodwork was as it should have been, and so on. Meanwhile, the patient (and her doc) had plenty of their time wasted, went through all kinds of stress, and even the insurance company went through a few contortions in its obstructive efforts. One might imagine that the medication in question would be a costly item. That is, worth the insurer’s while to fight tooth and nail to avoid paying for. One would be wrong: $15 for a 30-day supply. Hardly cost-effective for the insurer’s personnel to be quibbling over, let alone a valuable use of the patient’s or endocrinologist’s time. The policies and procedures of the insurance company which caused this needless exercise in inefficiency and aggravation, in a vacuum, probably sounds entirely reasonable. They would probably come across as being intended to avoid wasteful or fraudulent expenditure of resources. They might even be modeled after governmental/regulatory policies, such as those of CMS. Conceivably even mandated, such that an insurer not having such policies on file risks fining or other punitive action. After all, we have seen more than a few examples of governmental efforts to root out “waste, fraud, and abuse” whose costs in funding, manpower, and other resources have, year after year, been multiples of whatever they have claimed to recoup. Spending dollars, in other words, to save pennies. You’d imagine, at some point, an agency would take note of such poor returns, and seriously overhaul if not eliminate the purported “cost-saving” mechanisms. Certainly, if said agency were a private business, it wouldn’t have a rosy long-term outlook if it were routinely engaging in net-loss behaviors.And, then, there’d be the little matter of competing against other businesses…not just in terms of which outfit had the more adaptive approach, but also which was pleasing rather than aggravating its customers.  A governmental entity, on the other hand? Well, no competitors there. Also, evidently no need to keep an eye on the bottom line; if anything, operating at a deficit seems to be preferred…it might just get you more funding next year. And, if you think doing battle with an insurance company is a trial, just wait until you try fighting City Hall and its infinitely-larger bureaucracy. Are those really the only two choices? Devil vs deep-sea, frying-pan vs fire? We’ve sure been led to believe so. Fortunately, other options are beginning to gain traction. Direct Primary Care (DPC) models, for instance, and HDHP/HSA plans, which put decision-making back where it belongs-in the hands of patients and the physicians they choose.