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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

#121

Post by sorokod »

Scoundreller wrote: post #99
sorokod wrote: post #87

Earlier quoted context omitted.

And this relates to the article how? Ultimate, what is described is an insurer tying to minimize the payout on a claim same as they have been doing from the dawn of time except here it's particularly nasty as people suffer and die.

The beef in the article seems to be "We're not paying for it, because it's not in our guidelines" vs. "Doctor thinks this patient is more special than the guidelines" Where in the article says that the insurance provider was trying to minimize the payout on the claim? Insurance companies really hate paying for things that don't work (or have a low likelihood of working). Even more than paying for something expensive…

> "“So we get a phone call here to my staff saying that the pharmacist – not the doctor, but the pharmacist – to the PBM called and said they are denying the drug.”

The reason given: The patient should have surgery to remove his kidney first."

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

#122

Post by c3534l »

threezero wrote: post #63
mevile wrote: post #45

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 drawbac…

Kaiser’s system works better than a lot of others, but for me having to drive 40 minutes for a prescription is outrageous when I have 20 other pharmacies in a 15 minute radius.

KP will just mail you drugs. That how I get mine.

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

#123

Post by Scoundreller »

sorokod wrote: post #121
Scoundreller wrote: post #99

Earlier quoted context omitted.

The beef in the article seems to be "We're not paying for it, because it's not in our guidelines" vs. "Doctor thinks this patient is more special than the guidelines" Where in the article says that the insurance provider was trying to minimize the payout on the claim? Insurance companies really hate paying for things that don't work (or have a low likelihood of working). Even more than paying for something expensive…

> "“So we get a phone call here to my staff saying that the pharmacist – not the doctor, but the pharmacist – to the PBM called and said they are denying the drug.” The reason given: The patient should have surgery to remove his kidney first."

Notice that the doctor didn't disagree with that being a course of treatment for this disease. Their response was that the patient was too ill for that surgery - a detail that wasn't known to the PBM.

Either the issue is:

1) Kidney removal shouldn't be a course of treatment (unknown based on the details provided). Keep in mind, the same insurer would be paying for this, and it isn't cheap, so it's not as ridiculous as it sounds.

2) Patient status with regards to surgery wasn't communicated to the payor, but should be a part of that process. Or it was a part of the process, but it was omitted.

3) Kidney removal should be a course of treatment, but the doctors didn't want to go through with it anyway, and made up some reason after-the-fact to continue to support their beliefs.

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

#124

Post by zaroth »

Gibbon1 wrote: post #112
imglorp wrote: post #19

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 me…

Was talking with my endocrinologist. She said insurance companies are now limiting the amount of insulin she can prescribe. She'll have a patient who's been doing fine with 30 units a month and the insurance company will cut it to 25. And then to 20. My theory is specialists, hospitals, insurance and drug companies are trying to swipe everything that isn't nailed down before it all blows up.

FYI, a 10mL vial of U-100 insulin is 1000 units. I don’t think you can buy less than a 3mL vial (300 units) which is a pen cartridge and I think even those are only sold as 5-packs.

I’ve never heard of an insurance company trying to reduce an insulin dose. They definitely pushed back on the number of test strips they would cover (e.g. 5 strips/day vs 7/day) where a prior auth was needed to get coverage at the higher quantity.

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

#125

Post by ta0987 »

hestipod wrote: post #100
ta0987 wrote: post #84

Earlier quoted context omitted.

Logically, yes... But an acquaintance with Canadian relatives told me he knows a middle aged single man that was denied a knee replacement he needed because of these trade-offs. Left with decades to live, partially disabled, because: "Old? No family? Well fuck that guy then."

Every time this discussion comes up people tell stories of "things they heard" but I hear very little first hand experience that validates them. I have had discussions in the past with my very right wing relatives about social healthcare and quality of life abroad (where I have lived and they have not) and they always had a pocket full of stories they heard from someone that undid anything I said in their minds. A mo…

I sympathize, that's exactly what I used to assume. That there are outliers and horror stories for every system and in isolation the stories are inconclusive. Then I met this guy, in person, whose actual Canadian relatives went through this shit. Then it became real. Obviously my internet comment is not the same experience for you, being one step removed and coming from an Internet Random. And yet, having had the experience relatively recently I decided to share.

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

#126

Post by jdsully »

Scoundreller wrote: post #105
jdsully wrote: post #103

Earlier quoted context omitted.

> Of course, you're always free to pony up your own cash to pay for a treatment that isn't covered by your insurance With the big caveat that you cannot pay for "higher quality" of any services that are covered even if you want to.

90% of the population lives within 100km of the US border. Unless it's a life-or-death emergency (where the ED has guidelines to see you right away anyway), every Canadian has the option of paying for any level of service they want, even otherwise covered services. Then there are the firms that walk the line and charge you as "preventative health" services.

Not every Canadian is admissible to the USA, and as a sovereign nation our policy should stand on its own.

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

#127

Post by Scoundreller »

jdsully wrote: post #126
Scoundreller wrote: post #105

Earlier quoted context omitted.

90% of the population lives within 100km of the US border. Unless it's a life-or-death emergency (where the ED has guidelines to see you right away anyway), every Canadian has the option of paying for any level of service they want, even otherwise covered services. Then there are the firms that walk the line and charge you as "preventative health" services.

Not every Canadian is admissible to the USA, and as a sovereign nation our policy should stand on its own.

Most are, and for those that aren’t, most other Western countries can't check Canadian police records and readily admit Canadian citizens.

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

#128

Post by alistairSH »

rosser wrote: post #48
alistairSH wrote: post #42

Earlier quoted context omitted.

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.

Sure, but the fact remains that by sending you to an ER instead of a GP's office caused an increase in cost to everybody in your risk pool. It's an inefficiency that shouldn't exist.

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

#129

Post by tomp »

Scoundreller wrote: post #67
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…

Canadian here. We also have decision makers that decide what gets covered or not. It's stupid not to. We shouldn't plunder health care funds on $1m per year of life saved interventions when you can spend that on 100 interventions costing $10k per year of life saved. It works pretty well (something like 15th longest life expectancy). Of course, you're always free to pony up your own cash to pay for a treatment that is…

> you're always free to pony up your own cash to pay for a treatment that isn't covered by your insurance

Is that actually true? AFAIK (from second hand) there is no private insurance in Canada (i.e. far worse than e.g. UK), so you cannot get e.g. MRI by paying for it (and skipping the "official" waiting line of 1+ year).

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

#130

Post by Scoundreller »

tomp wrote: post #129
Scoundreller wrote: post #67

Earlier quoted context omitted.

Canadian here. We also have decision makers that decide what gets covered or not. It's stupid not to. We shouldn't plunder health care funds on $1m per year of life saved interventions when you can spend that on 100 interventions costing $10k per year of life saved. It works pretty well (something like 15th longest life expectancy). Of course, you're always free to pony up your own cash to pay for a treatment that is…

> you're always free to pony up your own cash to pay for a treatment that isn't covered by your insurance Is that actually true? AFAIK (from second hand) there is no private insurance in Canada (i.e. far worse than e.g. UK), so you cannot get e.g. MRI by paying for it (and skipping the "official" waiting line of 1+ year).

There's nothing stopping a US insurer from selling an "International" plan to Canadians.

As far as I know, none have tried. Either the demand isn't there, or there's a huge untapped opportunity (doubtful).

There are a few organizations that will arrange for your healthcare in the USA, but the Canadian demand wanting to pay to bypass the Canadian system isn't great. E.g. Cleveland Clinic has a Canadian branch, but just one office in Toronto.

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