I have been away from my desk of late, as a recurred back spasm has made sitting in my fancy-schmancy ergonomic chair extremely painful, and has made getting up after sitting in my fancy-schmancy ergonomic chair even more painful. Back trouble is part of the human condition: our brains have out-evolved our spines, and, however much I enjoy having hands and opposable thumbs, my symptoms last week are par for the course for walking around erect since something in my baby’s brain told me there was an alternative to crawling.
Being the owner of a small business, my medical lot has fallen in with Mr. Obama’s Health Insurance Syndicate. Such few alternatives that there are remain prohibitively expensive, and, but only in comparison, Mr. Obama’s insurance is “affordable.” It is also a locus classicus of “buy cheap, get cheap”: simply finding a doctor who will accept your Covered California “coverage” is a crap shoot. Literally: I’m not the only person to have had the experience of, after selecting a doctor listed as in-network by the Doctor-Finder-inator, showing up for an appointment and being told that they don’t accept Covered California…and would you please get out of the first class coach with your second class ticket.
The trouble started a couple weeks ago, when I was attempting to get out of bed. My back spasm was back in acute mode, which meant that I couldn’t straighten up, and that putting weight on my right leg was extremely painful. I’d been through this before, and I knew that the combination of ibuprofen and a muscle relaxant would, in a few days’ time, have me standing up straight again. The problem was that my reserves of S****, my tried-and-true muscle relaxant, were nearly depleted. I thus found myself in need of the doctor I’d been doing without since I moved to Pasadena. With a dining room chair pulled up to the desk, I searched through Mr. Obama’s Health Insurance Syndicate’s website, and found the name of a physician who, rara avis, actually was part of Mr. Obama’s Health Insurance Syndicate network.
I approach doctors with low expectations: for me, they fall into two categories, barely tolerable and intolerable. In this case, the doctor was of the former group. She correctly observed that I could barely move, and prescribed F****, a muscle relaxant which she said was every bit as good and side effect-free as the S**** I’d suggested.
And, oh yes, how much laudanum would I like to go with that?
I picked up the F**** (along with the very few codeine-laced acetaminophen tablets I’d requested), and, with no help from the morphia, was promptly sent into a most uncomfortable opium dream, which repeated itself when I gave the F**** a second chance. As we regularly operate heavy machinery here, I had that and other very good reasons not to wish to be incapacitated by medication, and, thus, called the doctor to ask for the S**** I’d wanted in the first place.
The next scene of the drama played itself out in the pharmacy. I was in a great deal of pain (the F**** had worn off by this point), and was looking forward to getting something into my system that I knew would help. The young lady behind the counter produced the bag with the bottle of 30 S**** tablets – and it carried a $112 price tag. That ought to have been the five bucks agreed upon by Mr. Obama’s Health Insurance Syndicate, but a second spin of the prescription roulette wheel showed that S**** was a “non-formulary” medication, and would, at the very least, require “pre-authorization” and we can send the paperwork to your doctor in the morning. (This despite the fact that, in the past, S**** had been covered by Anthem.)
Recall that I was in a great deal of pain and hobbling about with the aid of a walking stick. Despite the fact that I was standing there with the cane, the clerk made me stand at the counter while she typed Lord knows what into the computer for several excruciating minutes. That only made it more clear that I was in urgent need of the S****, and that I wasn’t going to be able to wait for the several days required for my doctor, Mr. Obama’s Syndicate and the pharmacy to decide that I could have the medication.
I should make clear that the great attraction of S**** for me is that it produces nothing in the way of opium dreamlike side effects, and is most certainly not a drug of potential abuse. Compare that to the ease with which I was able to obtain the opioid pain reliever. Getting laudanum’s first cousin is easy and cheap; getting the drug you know works is a big production and expensive. Small wonder we have the problem we do with pharmaceutical opioid addiction.
I had no choice but to cough up the hundred and twelve bucks for the S**** (and almost took out one of those chip card-readers with my cane while paying for it.) Naturally no explanation was forthcoming from the pharmacy as to why S**** was non-formulary. For that rather important piece of information, I was directed to my insurance carrier. (The pharmacy, in other words, was using the “we’re just obeying orders” excuse.)
I called Anthem the next day, pressed “4 for pharmacy” and, after about ten minutes on hold, was connected to a human being of sorts. I asked my thoroughly reasonable question – “why is S**** non-formulary?” – to which the answer was “it’s non-formulary…because it’s non-formulary.” I’m not kidding. I proceeded to point out that, as a paying customer, I was entitled to an actual explanation of why something wasn’t covered by my “affordable” insurance. The answer: “I’m not a medical professional.” In other words, the woman by her own admission had no idea what she was talking about and was completely unqualified to answer a line devoted to pharmacy calls. (Why else would someone push 4 for pharmacy but to discuss a point regarding pharmaceutical medication? Based on my experience, pleasure of conversation would not be an answer to that.) She then told me that the FDA decided what was non-formulary in conjunction with Anthem, which was about when I lost my temper.
Finally, the medical amateur at Anthem did what the pharmacy did: she blamed someone else and passed me on to them, “them” being Express Scripts, who contract with Anthem for the processing of pharmacy claims. (Now that it was Express Scripts’ fault, the line about Anthem and the FDA would have to have been a lie.) My call was then transferred, and, while the mental faculties of the woman at Express Scripts were decidedly superior to the circular-reasoning woman at Anthem, she provided nothing in the way of an answer. Indeed, she blamed Anthem.
The Express Scripts woman was, however, able to start the pre-authorization process on a prescription which had already been filled, and explained that time was of the essence, as I only had seven days’ time to obtain the authorization and have the pharmacy refund my $112, minus the deductible. Her advice continued in Huxleyan mode: I should tell the doctors’ office to call in the request for pre-authorization. Yes, they would have to sit on hold for half an hour, but, were the request submitted in writing, it would require “48 business hours” (it was laugh, scream or cry at that one…I opted to laugh) until it was processed.
Next call: to the doctor, to explain exactly what I was told would be needed to fill in the pre-authorization form. I’d tried another medication. I hadn’t tolerated it, because it made me into a drooling vegetable. I had taken S**** in the past numerous times, and always with success.
Perhaps my mistake was that my reasoning was linear rather than circular, for, lo and behold!, Anthem rejected the request for what was still being called pre-authorization, even five days post the filling of the prescription. The only explanation offered was that I would need to try two other drugs before they would pay for the one which I knew was effective. In other words, Anthem was willing to pay to fill four prescriptions (i.e. the F****, the other two they were requiring, and, finally, the S****), but they weren’t willing to pay to fill two (i.e. F**** and S****). They also expected someone in a great deal of pain to walk around shaped like a question mark for the week (at least) it would take to satisfy their requirements. Although, true, they’d pay for all the oxycodone I wanted to get me through their wheel-spinning.
I asked whose illogical decision this had been. The nurse told me that “it says a doctor reviewed the request.”
We now know what happens to the bottom 5% of the medical school class.
At least the S**** helped, so much so that I decided that the pain had reduced itself to the point at which it was an annoyance with which I could live. A few days later, I had to upgrade it to problem status again, made an appointment with the doctor, and asked for a refill of the S*** prescription, specifying that I wanted only enough pills to get me through to our appointment. There was no sense in paying cash for more tablets than I needed. The pharmacy automaton (this one really is an automated voice) called about an hour later, and I went to fetch and pay later that evening. “That will be $25.00,” said the pharmacist.
Whoa. That’s not the cash price of anything behind the pharmacy counter, so it had to be an insurance co-pay – the pricey co-pay which goes with name-brand drugs. (The form of S**** always under discussion was the generic version.)
In other words, for no apparent reason, S**** was now (somewhat) covered by Anthem. (Of course, given the co-pay situation of which no one could possibly have been aware until they went to fill the prescription, I’d have done much better to have asked for a full supply of 30 rather than the 10 I’d requested for pecuniary reasons, as 30 tablets would have cost me the same as 10.)
The only conclusion one can draw is that the pharmacy insurance computer is nothing more than a slot machine. Some combination of functionaries, under-qualified doctors, IT people with no medical knowledge, self-aware computers, and, likely, monkeys with typewriters is responsible for the algorithm which decides whether or not patients are allowed to receive their medications in timely fashion. I’d even venture that the algorithm varies with the phases of the moon, and might even have a random number generator built into it as well. You go see a doctor, the doctor makes a diagnosis and prescribes a medication…and someone and/or something else votes as to whether or not you should have it.
It’s insane. And thinking about it is making my back hurt again.