Cancer patients are being denied drugs, even with prescriptions and insurance • Hacker News Board

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#11

Post by erentz » Sat, Aug 03, 2019, 5:22 PM UTC

lotsofpulp wrote: post #6

devoply wrote: post #2

> pharmacy benefit managers The qualifications to become a pharmacy benefit manager include a bachelor's degree, at least five years of experience as a pharmacist, and five years in health plan pharmaceutical management. So a bozo pharmacist can trump a doctor's judgment.

A pharmacy benefit manager is not a person, it’s an organization. In this organization are usually doctors and pharmacists (who have doctorate degrees also), who review medicinal claims based on the policies set forth by the payer (sometimes an employer, sometimes an insurance company, sometimes the government). They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is co…

> They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is covered under the plan rules.

I think it’s incorrect to say they don’t trump the prescribing doctors judgement just because they have a company policy they’re following. They also have the ability to override the policy. This means they are making a decision and when they default to what the policy says, if that goes against the doctors judgement then that is a decision they made to trump that doctors judgement.

This kind of “just following orders” logic is used a lot by people who want to absolve themselves of the responsibilities of their choices.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#12

Post by dylz » Sat, Aug 03, 2019, 5:23 PM UTC

lotsofpulp wrote: post #6

devoply wrote: post #2

> pharmacy benefit managers The qualifications to become a pharmacy benefit manager include a bachelor's degree, at least five years of experience as a pharmacist, and five years in health plan pharmaceutical management. So a bozo pharmacist can trump a doctor's judgment.

A pharmacy benefit manager is not a person, it’s an organization. In this organization are usually doctors and pharmacists (who have doctorate degrees also), who review medicinal claims based on the policies set forth by the payer (sometimes an employer, sometimes an insurance company, sometimes the government). They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is co…

For almost everyone in the US, is it not true that "claim for medicine is covered under the plan rules" being denied is effectively "you are not getting this medication"?

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#13

Post by xvilka » Sat, Aug 03, 2019, 5:24 PM UTC

It would be very funny if the managers or their relatives who promote these policies will meet cancer themselves. Then they will feel the human price of their profits increase.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#14

Post by hondo77 » Sat, Aug 03, 2019, 5:24 PM UTC

Just because they assume their Blue Cross policy is "the best" doesn't make it so. Multiple medical professionals during my current cancer journey (in the Fresno area, as it turns out) actually referred to Blue Cross as "the worst" for the reasons given in this article. My insurer, Cigna, has been great. Also, isn't it possible that the cCare doctor really was not following the right protocol and prescribing things improperly? I'm not going through cCare because I didn't like what I saw there.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#15

Post by iamleppert » Sat, Aug 03, 2019, 5:26 PM UTC

Instead of fighting them like they did, why not just go along with them and order the medications, throw them out just to get escalated to the right one? When I had to deal with CVS Caremark I frequently had to order things I didn’t need because it was part of their “protocol”. Rather than fight them, I would just go along with them because I knew fighting a company like CVS is pointless. I just threw out the stuff I didn’t need so I could get what I needed out of them.

When navigating systems like these you have to find ways of looking like the 90% even if you’re in the 10%. Any exceptions to their protocols will be met with resistance and delays as you have to make your way to some review board vs. dealing with the mindless lower level staff who have no decision making ability.

It’s what happens when you have executive management with MBA’s that have come from running customer service, consumer finance and call centers running health care.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#16

Post by DanBC » Sat, Aug 03, 2019, 5:29 PM UTC

sorokod wrote: post #3

Can't wait for the US health system to make it to the UK.

Something similar used to happen here with NICE guidance not recommending use of the meds, which is why the cancer drugs fund was set up.

After spending a billion or so on meds we found out that they mostly don't increase length of life and also cause nasty side effects. https://www.bmj.com/content/357/bmj.j2097

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#17

Post by caymanjim » Sat, Aug 03, 2019, 5:30 PM UTC

hondo77 wrote: post #14

Just because they assume their Blue Cross policy is "the best" doesn't make it so. Multiple medical professionals during my current cancer journey (in the Fresno area, as it turns out) actually referred to Blue Cross as "the worst" for the reasons given in this article. My insurer, Cigna, has been great. Also, isn't it possible that the cCare doctor really was not following the right protocol and prescribing things i…

I'm absolutely not defending the PBMs or what happened in this case, but $500/mo for that age group is the junk end of the insurance market. It's unfortunate, but they certainly don't have good insurance.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#18

Post by lotsofpulp » Sat, Aug 03, 2019, 5:30 PM UTC

dylz wrote: post #12

lotsofpulp wrote: post #6

Earlier quoted context omitted.

A pharmacy benefit manager is not a person, it’s an organization. In this organization are usually doctors and pharmacists (who have doctorate degrees also), who review medicinal claims based on the policies set forth by the payer (sometimes an employer, sometimes an insurance company, sometimes the government). They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is co…

For almost everyone in the US, is it not true that "claim for medicine is covered under the plan rules" being denied is effectively "you are not getting this medication"?

I guess, but the nuance is that the PBM is only doing what the payer wants it to do. If a state tells the PBM to only approve payment for certain medications under certain circumstances, I don't see the purpose of blaming the PBM for this. Similary, if an employer chooses a formulary that results in a denial of payment, it's the employer who chose to not cover payment for the medicine. The state or the employer can choose to pay for the medicine, but that is not up to the PBM.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#19

Post by imglorp » Sat, Aug 03, 2019, 5:32 PM UTC

I'm having exactly these problems, with exactly these companies: CVS and BC Anthem. Doctor writes prescriptions; some are limited in doses, some delayed, some with no copay, some priced barbarically, and some flat out refused. Then the doctor's office has wizards that help advocate and sometimes that works, sometimes there's a delay, and sometimes never.

In all cases, the patient suffers. They are already facing a medical condition, maybe serious, plus stress from missing work and home life, stress about the future, stress for paying for it all, and then along comes these sharks who will double it all with more stress and worry and anger. Then on top of that they don't get all the types and amounts of medicine their doctor actually wants, based on science and experience, so they will get inferior treatment in every way.

Yes we need to cut the price gouging. Adding friction at this interface is not the way.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#20

Post by lotsofpulp » Sat, Aug 03, 2019, 5:32 PM UTC

erentz wrote: post #11

lotsofpulp wrote: post #6

Earlier quoted context omitted.

A pharmacy benefit manager is not a person, it’s an organization. In this organization are usually doctors and pharmacists (who have doctorate degrees also), who review medicinal claims based on the policies set forth by the payer (sometimes an employer, sometimes an insurance company, sometimes the government). They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is co…

> They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is covered under the plan rules. I think it’s incorrect to say they don’t trump the prescribing doctors judgement just because they have a company policy they’re following. They also have the ability to override the policy. This means they are making a decision and when they default to what the policy says, if that…

>They also have the ability to override the policy.

From my understanding, they do not. At least not outside of a certain margin of error, since the payer (for example a state government or employer) would then blame the PBM for approving payment something it wasn't supposed to approve payment for, and hence seek reimbursement from the PBM or cancel its contract and go with another PBM.