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

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

#41

Post by darkerside »

lotsofpulp wrote: post #20
erentz wrote: post #11

Earlier quoted context omitted.

> 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.

What do you think is happening during the appeals process?

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

#42

Post by alistairSH »

rosser wrote: post #33
qrbLPHiKpiux wrote: post #21

Earlier quoted context omitted.

A patient was on Humira then went on medicare. Medicare would not cover Humira and this patient had to go on Remicade. The difference? Humira is able to be given by self at home. Remicade requires an infusion by a nurse.

I was once dating a woman who had vertically contracted Hepatitis C during her birth. We had an accident before I had completed my normal vaccination course. The first-line treatment in those cases is a dose of immunoglobulin containing the relevant antibodies. My insurance gave two choices: pay $800 out of pocket for the drug at any pharmacy that carries it (zero coverage offered, no recourse), take it to my doctor'…

Fine, guys. It's your money...

Except it's not their money. It's all of our money, as the whole point of insurance is pooling resources to hedge against any individual risk. Not that I blame you - the implementation of some policies is completely asinine.

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

#43

Post by mnm1 »

These PBMs need to be eliminated along with the insurance companies that deal with them. The blame is two fold and this can be seen as a conspiracy to commit murder. Maybe not legally, of course, as these companies (pharmacy and insurance) are clearly allowed to murder people without consequence. Insurance companies whole business plan is based around this notion of providing the absolute minimum care when a patient is really sick and needs it the most. Who'd have thought there is another way to die in America just so pharmacies save a few dollars? It's widely known about insurance companies. What other companies have such legal power of death, I wonder?

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

#44

Post by taneq »

tasty_freeze wrote: post #36

One entirely maddening thing is that the ACA was labeled as having "death panels" that would decide who lives and dies. That phrase was powerfully effective in making large group of Americans strongly oppose the ACA. Even if they knew nothing else about the ACA, they knew they didn't want death panels. But as this article demonstrates, if we care to use the inflammatory "death panels" label, we already have them. It…

The rational, informed decision is that the government should run its own medical R&D. But no, we can't do that because muh freedums.

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

#45

Post by mevile »

If you're an employer in California and want to choose a provider that will not have to deal with this you might want to consider offering Kaiser to your employees. There's benefits and drawbacks, but one of the big benefits is that they're vertically integrated and the doctors, labs, pharmacies are all part of the same organization. I would think that would help avoid this specific type of situation.

The big drawback is that your employees would need to live near Kaiser facilities. In the Bay Area they are everywhere though and easy to get to. Making use of any doctor or service outside of the Kaiser network is probably not covered.

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

#46

Post by cheeky78 »

tasty_freeze wrote: post #36

One entirely maddening thing is that the ACA was labeled as having "death panels" that would decide who lives and dies. That phrase was powerfully effective in making large group of Americans strongly oppose the ACA. Even if they knew nothing else about the ACA, they knew they didn't want death panels. But as this article demonstrates, if we care to use the inflammatory "death panels" label, we already have them. It…

"But as this article demonstrates, if we care to use the inflammatory "death panels" label, we already have them."

It's not inflammatory when it's true. When the government runs our healthcare, choices are removed and someone else gets to decide if you should get surgery needed or not...and many times this is life or death.

At least now, if a cancer patient gets denied drugs, they can go to another doctor or get a second opinion.

All of my elderly relatives live in Canada and come over the border for any major surgery. This is mostly because the wait times are sometimes in the years..when they can just get private care in the US and get it done in a matter of weeks.

Doctors are also usually maxed out when it comes to patients, so individual care is lacking and they usually just want to try to push you out the door.

I also feel like I should have a say in someone's behavior, if I'm paying for their healthcare with my tax dollars: smoking, drinking, risky behavior, etc.

I've lived in countries with universal healthcare and the quality is sub-par compared to the US/private care. Sure private care can be improved, but it shouldn't be ripped out and replaced.

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

#47

Post by mnm1 »

tasty_freeze wrote: post #36

One entirely maddening thing is that the ACA was labeled as having "death panels" that would decide who lives and dies. That phrase was powerfully effective in making large group of Americans strongly oppose the ACA. Even if they knew nothing else about the ACA, they knew they didn't want death panels. But as this article demonstrates, if we care to use the inflammatory "death panels" label, we already have them. It…

Seriously. People who aren't aware of the current death panel situation and claim that the aca or future single payer healthcare will bring them are incredibly naive, uninformed, and stupid. They sure as hell haven't lost a relative to our current death panels. But of course, what do they care? Until it's happening to them, they will continue to believe whatever idiotic political bullshit their party or tribe subscribes to and eschew any logic or reason whatsoever. These people comprise most of our electorate, sadly.

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

#48

Post by rosser »

alistairSH wrote: post #42
rosser wrote: post #33

Earlier quoted context omitted.

I was once dating a woman who had vertically contracted Hepatitis C during her birth. We had an accident before I had completed my normal vaccination course. The first-line treatment in those cases is a dose of immunoglobulin containing the relevant antibodies. My insurance gave two choices: pay $800 out of pocket for the drug at any pharmacy that carries it (zero coverage offered, no recourse), take it to my doctor'…

Fine, guys. It's your money... Except it's not their money. It's all of our money, as the whole point of insurance is pooling resources to hedge against any individual risk. Not that I blame you - the implementation of some policies is completely asinine.

It's "theirs" in that they're the ones with absolute discretion over its disposition. It's a turn of phrase, and not meant to be taken strictly literally.

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

#50

Post by lotsofpulp »

darkerside wrote: post #41
lotsofpulp wrote: post #20

Earlier quoted context omitted.

>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.

What do you think is happening during the appeals process?

They're not overriding policies set forth in the formulary during appeals process. Obviously, this problem space is hard to define so there is room for error and difference in judgement by people approving and denying, so an appeals serves the same purpose as it does in the court system, to get a second or third look on a decision to see if it was correct or not.
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