POSTED ON SEPTEMBER 30, 2009:
Why are insurers blocking H1N1 treatment prescriptions?
I got swine flu. Five days later, I was at death's door because my evil insurance company wouldn't honor my doctor's prescription. Memo to future revolutionaries: If you require a firing squad for the executives of the Health Insurance Plan (HIP) of New York, I'm handy with a rifle.
I wasn't worried at first. A little sneezing, slightly achy joints. I figured it was my usual bout of fall allergies. There's usually nothing to do but suffer. But I felt worse each day: achier, more congested, stiffer, headache, fevers. The third night was bad. I went to bed under a pile of comforters, chattering uncontrollably. Then nightsweats. I checked my temperature: 103.7. When your temperature looks like a classic rock station, it's time to see the doctor.
I've known my general practitioner for decades. So I pay out-of-pocket to see him even though he's not on HIP's list of plan-approved doctors. Hey, what do you expect for $749.01 a month?
My ordeal with the insurance company began when I went to fill my prescription for Tamiflu, an antiviral medication that is widely considered the standard treatment for swine (and other types of) flu.
"Your insurance isn't going to cover this," the pharmacist said. "You would need a pre-approval from your doctor."
"But that's a prescription," I said, motioning to the white slip of paper in her hand. For younger readers, I come from a generation when a doctor's prescription was all you needed to get a medication.
"It's not going to work," she said, slowing her speech for emphasis. "This drug is for people who have the flu."
"Um...I have the flu."
"You have the flu?" She looked shocked.
Because Tamiflu or another drug called Relenza can significantly reduce flu symptoms if taken less than 48 hours after the onset of symptoms, people have been hoarding and taking anti-viral drugs prophylactically--especially in New York City. Given what was about to happen to me, I admire the hoarders. Smart.
I called my doctor. No answer; left a message. Waited. I called back. Got his assistant, who patched me through. I explained the situation. "Put her on," my doctor said.
I offered my cellphone to the pharmacist. She recoiled in horror. "You have the flu! I'm not using your phone!" She believed I had the flu enough to shriek like a wee girl. So why did she need to confirm it with my doctor?
I asked my doctor to call the pharmacy. "Right away," he promised.
Wait. Wait. Wait more.
I called back. "Wait. Are you already at the pharmacy?" he asked. "You want me to call where?"
At this point I began to lose my mind.
An hour passed after my doctor and pharmacist exchanged the required bureaucratic pleasantries. She returned to the counter. "I'm sorry, Mr. Rall," she said, "but your doctor is going to have to call HIP to get their advance approval. It will take him quite a bit of time...it's complicated, especially for doctors."
Especially for doctors?
Remember, this isn't heroin. It's Tamiflu. The street value of this stuff isn't that great, and it's a really, really bum trip. My brain may be baked from a week of triple-digit fevers, but I want to know: Why the hell would an insurer make it more difficult to get the main drug prescribed to treat the number-one most-talked-about disease in America, one that's a probable pandemic? Shouldn't HIP and other insurers be shoveling these yellow and white capsules out the door, trying to keep their own costs down by getting as many flu victims to recover as quickly as possible?
What the hell is a "pre-approval"? If a doctor prescribes a drug, why isn't that good enough for the health insurance company?
Oh, and why doesn't the federal government make Tamiflu available free? Hey, President Obama: What part of "pandemic" do you not understand?
Another hour went by. My pharmacist's phone rang. She winked at me. "Everything should be fine now," she said.
Everything was not fine.
I was getting sicker and sicker, just sitting there. My head reeled; an invisible C-clamp tightened behind each ear. I could barely breathe. It felt as though there were shards of glass stuck in my lungs. Every breath hurt. I barely had enough energy to stand up and take a step. My fingers were bluish-gray (an early sign that breakdown of the cardio-pulmonary system is imminent.) I coughed and caught a ball of phlegm in a napkin. It was soaked in blood.
Four hours and 12 phone calls after I arrived at the pharmacy, I went home empty-handed. HIP's approval still hadn't appeared in the pharmacy's computer system.
When swine flu appeared in the U.S. this spring, the government prompted hysteria, predicted the deaths of as many as 90,000 Americans. Now they're going to the opposite extreme, downplaying a genuine threat by trying to ignore it. They're no longer even tracking new cases. And Obama Administration health officials are now selling an official line--for most people, swine flu symptoms are no worse than those of any other random flu--that isn't quite accurate.
For example, while it's true that children and the elderly are in high-risk categories for swine flu, "40-year-olds are the group most at risk of developing life-threatening complications from H1N1," according to Canadian researchers cited by the Montreal Gazette. (Centralized data collection is a big advantage of a national healthcare system.)
Another difference is that swine flu is much more likely to cause viral pneumonia, the most common life-threatening complication of flu. It is not just another flu.
Lord knows, it's not like any other flu I've had. I spent that night coughing up blood and downing aspirins to try to keep the fever down. By way of comparison, I've been thrown down two flights of stairs--and swine flu is worse. I had pneumonia last year; it sucked hard, but it was a joke next to this.
I went back to the pharmacy in the morning. Still nothing. I called HIP. Unsurprisingly, their voice recognition voicemail tree had some trouble understanding my voice by this time. God forbid they should hire someone in India to actually answer the phone. Finally--success. Sort of.
"The pharmacy needs to enter the approval code," the HIP lady explained. She read me a long number. I gave it to the pharmacist. She typed it into her computer. "No. Still nothing," she said.
She didn't look surprised.
"Would you like me to call HIP?" the pharmacist asked.
"I thought you'd never ask," I replied.
Half an hour, an overnight and about two pints of phlegmy blood later, I had my Tamiflu in hand. "$87.12," demanded the pharmacist.
I asked her how much it would have been out-of-pocket, without insurance.
"$112," she said.
Losing that night has diminished the effectiveness of the drug. It took three days more of feeling like death just to advance to the stage of feeling like crap. Now I'm settling into a nice, comfortable state of wretched. I just read that a recent ABC News poll says that 32 percent of Americans think the current healthcare system is just peachy. Let's hope they don't catch swine flu this winter.
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