• Adventures in insanity

    I’ve detailed before how annoying it can be to get my medication. Here’s the basics again:

    I have a chronic illness.  I do not have this illness because of anything I did.  There is no way I could have prevented it.  I eat right and I exercise.  I don’t smoke, I don’t do drugs, and I don’t abuse alcohol.

    I work hard; I have health insurance.  I pay for the premiums.  I pay all the co-pays.  I follow the rules.

    For my illness, I take medication.  This medication is serious, with bad potential side effects, and it is not something you would want to take.  But, since I want to be well, I take it.

    I need to refill my prescription every three months. But in order to do that, I need to have my labs drawn first. My doctor requires that some laboratory values be monitored. Let the insanity begin.

    Indiana University, in its infinite wisdom, changed the health care plans for the gazillionth time on January 1. This means that the laboratory I used to have to go to (which is NOT an IU lab – crazy) is no longer covered. So I needed to search for a new lab that would qualify as in-network. Of course, that meant that the standing order I had at the old lab needed to be reissued. So I had to call my doctor and wait for them to get me a new prescription for my labs. That took a few tries, because they couldn’t understand why I needed a new prescription. But, eventually, I got it.

    I went to the new laboratory this morning. I didn’t know, though, that the insurance company changed the reimbursement for labs. In the old insurance, if you went to an in-network lab, there were no co-pays. With my new insurance – which costs me more than three times what the old insurance cost – I have a personal deductible, a family deductible, and then co-insurance. When the laboratory asked me today where I stood on my deductible, I had no idea. So I just paid the entire amount. Hopefully, if I have met the deductible, the insurance company will pick that up and refund me the money.

    I’m not holding my breath.

    Now back to my prescription. The old insurance had already flipped me three times to different pharmacies. At last, I had wound up at a specialty pharmacy, as the medication I take is not your usual run-of-the mill drug. It is however, generic, and not crazy expensive. It’s just not easy to get.

    Turns out the new insurance requires a new pharmacy. I still need to go to their mail-order option, though. I was given a website by which to get information. I went there, registered, and tried to navigate the crazy in order to learn how to order my meds.

    This is a good time to point out that (1) I am an expert in health insurance and health policy, (2) I am an expert in information technology and the Internet, and (3) I’m a physician and know what I’m talking about in practicing medicine. The website nevertheless floored me. After one hour, I finally found a link by which I could request they contact my physician for a new prescription (necessary because I had to change pharmacies). But then I saw I had to tell my doctor that they were going to contact her first. So I went back and left a voicemail for my doc telling her that the call would be coming from the new pharmacy. Then I went back to the website.

    New problem. I kid you not, the links on the pharmacy website are broken. They don’t go where they should. So there is no way to get the pharmacy to contact my doc to ask for a new prescription. So I’m left with a form I can download and then give to my doctor. So I went back and called her again. This time I left a voicemail asking if I could email or fax them the form so that they could fill it out and send it to the pharmacy.

    It’s Friday afternoon. I’m less than optimistic that they will respond this afternoon. I even less optimistic that when I do talk to them next week that the rest of what has to happen will come off without a hitch. I need to fax my doc the form. I need them to check my labs and see that they are normal. Then, I need them to fill out the form and fax it back to the pharmacy. Then, I need the pharmacy to call me to get my address so that they can send me the drugs. They will also need to get a credit card from me, as my new much more expensive insurance carries co-insurance for drugs that I didn’t have before.

    There’s no way this will go off without a hitch. I cannot believe how much time I’ve spent on this. What a waste.

    Best in the world, my ass.

    • Matt Welch is the editor-in-chief of the libertarian publication Reason. Everyone should read about his experiences with socialized medicine. Puts things in perspective. He makes a very good case for the existence of positive liberty, but cannot quite accept it. His care is cheaper, much quicker and easier, but something must be wrong.



    • As someone who also “gets” to take a fair share of medication (liver transplant plus post-colectomy UC), I can sympathize with you. I work for a company who is head quartered in another state. This leads to our insurance being semi-overlooked at times. To be honest, I really appreciate everything my HR department has done for me, but it makes for difficult circumstances.

      We too have the situation where our labs are handled in facilities that NONE of our doctors or hospitals are located. The prescription benefits seem to ever change, but thankfully, I’m not required to purchase my medication mail-order… yet.

      I did have one bit of advice though. From my personal experience, it’s much easier to just ask the person at the counter (of the lab, ER, whatever) if they can send you the bill. I explain that I am almost certain that I have met whatever deductible/copay-max-out-of-pocket. (It helps that for pretty much every visit of the year, this is the case). I have just tried the “pay up front, get the money back later” and it’s a significant hassle. Of course, if they really do owe you money, you will get reimbursed. I just prefer to let the insurance reps do the arguing, and for me to only write one check.

    • Now think how much fun this is for a patient with a high school education and with only a cell phone. However, you can file your taxes electronically. go figure.
      Now as an economist have you attempted to calculate the cost of you managing your healthcare and billing the insurance company for that service?

      • I think it’s important to flesh out what it means when you say “with a high school education”. I only have a B.S. in CS but I find a certain sick enjoyment in reading through legalese documents. Whether it’s state code when a car insurance agency decides they don’t really think they have to pay fair value on my car, or if it’s the policy documentation that HR doesn’t hand out in their yearly meetings. I don’t think that I am at all normal in this respect. Most people see a legally-technical document and turn and run.

    • Someone should really do this back of the envelope calculation

      # of health insurance or health care customer care reps in the US * # calls per rep per year * (2*average minutes spent on support call + average minutes spent by care rep on problem outside of call + average minutes spent by consumer addressing problem outside of call) * $ value of a minute = X

      I bet X is a very, very , very, very big number.

    • Reminds me of a story that involved many hours of back and forths between many parties over a prescription that they ultimately found out cost ~$18, after which they just handed over a $20 and went on their way.

      I realize that the point of this story is how the reimbursement system has become so convoluted and byzantine that even an expert of incontestable authority can become incapacitated by it all – but just as an intellectual exercise, how long would it have taken, and what would the cost have been if you’d simply paid straight cash for everything, and how long would it have taken?

      • Sometimes that just isn’t possible. I don’t really know if I’m really that far outside the norm, but just the other day I found myself at the pharmacy with a very special antibiotic. I was glad that I had semi-decent insurance and didn’t have to foot the entire bill for a 2 week supply at $35+ per pill.

      • The cost is the least of it. Most of this story involved the crazy things I need to do just to get them. Payment is the last piece.

        Bottom line, though, is that while I can afford them, most people cannot. The system is insane.

        • Interesting. As a reader I got the idea that other than the call to the doctor, the majority of the time and effort went into steps that were only necessary to avoid direct payment* – searching for in-network labs, getting the medication through a pharmacy that your insurer deals with, filling out their forms, etc.

          If you were an equally well compensated uninsured person who was willing to go to a walk-in clinic and pay spot cash for whoever could deliver the good or service needed as quickly as possible – what would the time differential have been?

          *Not a value judgment. If you pay through the nose for something, it’s quite reasonable to expect the folks who are in the business of delivering the said something to make the process as simple and efficient as possible, and no one without a Scrouge-McDuck sized pile of doubloons in their basement would be willing to pay out of pocket for something they’d already paid for.

          • “If you pay through the nose for something, it’s quite reasonable to expect the folks who are in the business of delivering the said something to make the process as simple and efficient as possible”

            A common business model today seems to be to make it as hard as possible for the consumer to extract services from the organization even though one has paid for the product. Case study: Sears.

            In a better functioning market, this wouldn’t happen. In Aaron’s case, he’s essentially captured by his employer. Since the individual market doesn’t work well and is more expensive, if he wants insurance, he has to take his employer plan and suffer the service.

            As for Sears, well, I learned my lesson, and I took my business elsewhere.

    • @Austin

      1. Interesting observation. This is probably an optimal strategy if you have a statutory monopoly. Seems like the further you diverge from a monopoly, the less the model holds.

      2. Anyone paying cash from Step A (doctor at urgent care clinic) to Z (receive medication) would have had a dramatically faster path to the final endpoint. IMO this is one of many reasons why we should move away from using insurance as a mechanism to pay for routine/non-acute care that costs less than, say, a transmission rebuild. No insurance, no capture, no labrynthine bureaucracy to navigate plus more competition equals faster, more convenient service at a minimum.

      Quick Example:
      A) Test:
      Simply purchase the blood lab test you want on at Health Testing Centers. Health Testing Centers then emails you a requisition form to bring to one of the below LabCorp locations. After you you have the blood drawn at one of the LabCorp locations below we email the results within 24-48 hours.

      B) Consultation:

      C) Prescription….

      Aaron may have had a special case, but there are fast, convenient options for people who are willing and/or able to pursue care outside of the third-party-payer megacluster.

      • Statutory monopoly? Have similar experiences in the duopoly cable/ISP/phone market around me: Comcast + Verizon. This is a well-known consumer problem throughout much of our capitalist system. My colleague has been struggling mightily to get a GE to address issues — covered by warranty — with a brand new hot water heater. My Sears case study exists in a market with many sources for large appliances. Clearly some are better at customer service, but my guess is many are not.

        Is this a rational tradeoff that consumers have made? Have we decided that we prefer lower upfront prices in exchange for crappy back-end support? Revealed preference suggests it is so. But I think there is also a fair amount of information asymmetry. There is a decent flow of new customers (or effectively so) for products only purchased infrequently (large appliances). There are search frictions. Pricing and options are famously hard to grok (ISP/phone/cable). One is handed a stack of papers to sign with tons of fine print for any installation or large purchase. What does all that stuff say? Who reads it?

        Far from a perfect market, even when it isn’t a monopoly.

      • “2. Anyone paying cash from Step A (doctor at urgent care clinic) to Z (receive medication) would have had a dramatically faster path to the final endpoint. IMO this is one of many reasons why we should move away from using insurance as a mechanism to pay for routine/non-acute care that costs less than, say, a transmission rebuild. No insurance, no capture, no labrynthine bureaucracy to navigate plus more competition equals faster, more convenient service at a minimum.”

        Here’s how it works in my world:

        1. Go to doctor (any doctor) and get prescription for lab tests and drugs.

        2. Go to lab (any lab) and have tests done.

        3. Go to pharmacy (any pharmacy) and pick up prescribed drugs.

        Total cash outlay at time of service: $0. (For some they might need to pay for the drugs and then be reimbursed. But even that payment is likely to be 1/4 to 1/10 of what someone in the US might pay.)

        ‘Course this is one-o-them evil socialist countries.

    • I have sleep apnea for about 10 years now.

      I use a device call a CPAP which provides a controlled flow of air via a simple mask so I can sleep a night. I can buy a new CPAP machine for under $200.

      If I want to get my Medicare insurance plan to help pay for the device I am required to get $10,000 sleep test to make sure I still need one.

      Assuming the gov doesn’t want malingerers to get take advantage of the system by getting a machine they don’t need.

    • Everyone hates to deal with insurance companies (and Governments BTW) so why not very high dedutibles?


      The state would provide insurance to all Americans but the annual deductible would be equal to the family’s trailing year adjusted income minus the poverty line income (say $25,000 for a family of 4) + $300. So a family of 4 with a trailing year adjusted income of $30,000 would have a deductible of $5,300. A family of 4 with a trailing year adjusted income of $80,000 would have a deductible of $55,300. Middle class and rich people could fill the gap with private supplemental insurance but this should be full taxed. This would encourage the middle class and rich, who are generally capable people, to demand prices from medical providers and might force down costs. They could opt to pay for most health-care out of pocket while the poor often less capable would be protected.
      It is not a perfect plan but it might help. Some deregulation of health-care would also help the poor gain access. The gauntlet that Doctors have to run these days to get to practice seems like an anachronism in today’s world. Let smart people get to practice medicine after on the job training. Let the medical businesses decide who is qualified to practice medicine. 12 years of training to tell if my child has an ear infection is overkill and reduces access to health-care for the poor.
      Another benefit of my plan is that it would encourage capable Americans (the rich and middle class) to be a counter weight politically against the providers.

    • Added:

      If we really think about it, we do not want the insurers to easily OK everything. Otherwise we the premium payer will have to pay more for insurance. After all in the end we pay for it all.

      If the truth be known we all want the insurance company to give us all we want to hassle everyone else.

    • one more point:

      if Government where efficient you could take them to court.

    • Cable is an interesting case, with lots of debate about the extent to which technical constraints make it a natural monopoly. That’s an interesting discussion, but the market for large appliances is probably a better analog for health care.

      It’s still not clear to me how much stock you have placed in the idea that a preference for real markets where irrational actors with imperfect information use prices to coordinate activity via transactions with non-zero costs has to be justified in terms of the formal solutions to the computational exercises at the heart of neoclassical econ. Given that the vast chasm that separates these idealized formalisms from real market conditions, is claiming that something doesn’t satisfy the prerogatives of market perfection as defined by a neoclassical GE simulation really a strong indictment that whatever real market is under consideration has “failed?” If so – compared to what?

      I have similar questions regarding the extent to which formal rationality can or should be used to justify the outcomes or properties of an emergent order like a real market in a real society. Neither our food, our dress, our behaviors, our languages, our laws, our homes, etc, etc, etc emerged as the outcome of a rational selection process. Virtually every essential activity that humans engage in falls somewhere between instinct and reason in the context of an order that emerged via evolution rather than intelligent design. Consequently, I don’t think it follows that any of the above should *necessarily* be discarded or substantially modified because they haven’t emerged as the consequence of a rational decision process.

      Real markets are far from perfect, but so are real people, and so are the conclusions they draw from imperfect models that attempt to simulate the essential features of markets. Consequently, I think that when it comes to evaluating the failures of what existing markets deliver relative to what a computational exercise says the outputs of an ideal market ought to be, a bit of caution is in order. Particularly when constructing policies to remedy market failures defined in this manner that will be translated through and imposed by an imperfect political system.

      How about you?

      • I agree. Yet I think it is still fair and valuable to point out the failures and limitations, on both (or all) sides. And, though it is not valuable (beyond rhetorically) to measure something real against something ideal to the point of unrealizability, it is possible to extract some useful information from abstractions that jettison some aspects of reality. It’s on the return trip to reality, the so-called “policy implications”, where extreme caution is warranted. Often things are oversold. Having said that, my guess is that nothing that isn’t oversold ever comes to pass. Sometimes the sell is the key to progress. Some things really turn out to be worthwhile, even if they could have been shouted down as unrealistic before attempted. Some economists really do have too many hands. I’m one of them, which I’ve freely admitted before.

    • Question – Why didn’t make a copy of the bloodwork order before giving it to the lab? Also if you are a doctor, why didn’t you write the order yourself?

      • 1) The lab took it and kept it on file. That was their procedure.

        2) Because that’s sorta considered unethical. And, there is a question of whether insurance will cover it then. Since I already paid for the insurance, I’d like them to cover it.

    • I too have a chronic illness that I did nothing to cause and that requires daily medication for the rest of my life. I cannot count the number of hours and the amount of money I’ve spent over the course of the last 12 years on exactly the type of issues you write about above. I too have insurance, pay my premiums, copays, and deductibles, budget for my medical expenses, and have significant expertise in healthcare. I can’t even think for too long about how ridiculous the whole system is, otherwise I get so angry and frustrated that it seriously impacts my quality of life. Thank you for giving voice to this issue.