“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”
Prescription For Danger
many people, Vacaville resident Sue Adair takes medicine daily, in her case,
for a couple of minor illnesses. Her new health insurance wouldn't cover one
drug she'd been taking for years, so her doctor ok'd a change to another one
her insurance company suggested.
Adair, patient: "I had a drug reaction. I had rashes that led to a doctor
visit and had blood tests taken which showed that I had liver enzyme
elevation. I'm absolutely convinced that the drug made me sick."
switched back to her regular medication and is now fine. However, she is
paying for the pills now, $120 per month. Her insurance promised it would
cover a medically necessary exception, but after two months of faxes and
phone calls -- what her husband calls delay tactics -- her insurance still
hadn't approved it.
Adair, husband: "They hassle you to the point where you quit and they've got
pediatrician Albert Goldberg says he prescribes the medicine that works best
for each patient, and insists there's a different among, say, various drugs
for ear infections. Marcia Jacobs says her insurance wouldn't pay for the
medicine Dr. Goldberg wanted for her 7-year-old.
Jabobs, San Rafael: "When you have a sick child, you just want your
prescription filled and whatever the doctor prescribes I think is better
than what the health plan thinks the child should have."
Physicians prescribing off-coverage drugs get insurance 'requests,'
requiring that the doctor review the patient's case, and either give in and
prescribe the preferred medicine, or make an individual, time-consuming
says he appeals to insurers several times a day, spending as much as 20
minutes per patient.
Goldberg: "Eventually we get the medicine. Now, how many times a day can I
do that? It's ridiculous, in the meantime, most patients and most physicians
won't do that, they can't do it."
pharmacist Paul Lofholm heads the California Academy of Pharmacy Owners. He
says insurance more and more won't cover first-choice medicine;
Increasingly, patients pay.
Kulemin, health plan member, Novato: "The drugs cost me $500 a month, I have
to pay out of my own pocket because the insurance I have won't pay for it."
Lofholm: "The insurance companies are pushing all of us around, they're
pushing the patient, the consumer, they're pushing the physician and they're
pushing the pharmacist."
drugs and dosages an insurance company prefers are called its 'formulary.'
We discovered your insurance formulary often depends on secret deals your
health plan makes with drug manufacturers. Depending on which drug is not
selling well, manufacturers give incentives -- what some call kickbacks.
Mayer, Pharmacist Planning Services: "These are billions and billions that
they are giving, kickbacks to put their drug exclusively on a formulary."
Pharmacist Fred Mayer heads a non-profit consumer drug organization. He says
insurers manipulate patients' choices, and are cashing in.
dropping a popular 20-milligram dose of cholesterol-lowering Lovastatin and
substituting the poorer-selling 10-milligram pill, we've learned one health
plan made $800,000 a month.
Mayer: "If your presecription is for Celebrex, the most popular arthritis
drug, your insurance may switch you to Vioxx instead, because it's
manufacturer, Merck, offers big incentives."
"These insurance executives get four, five or six million dollar salaries a
year and $16-to-25 million in bonuses; how do they do it? By managing the
is the state's biggest drug buyer. It was the only major health plan to
agree to speak to us. Formulary Chief Dr. Bill Elliott says non-profit
Kaiser is different.
Elliott: "There's no one getting rich off this -- there's no multi-million
dollar executive sitting in downtown Oakland who is getting paid the big
bucks to do this."
a doctor's committee picks the Kaiser formulary, based on safety, efficacy
and best deal.
usually can tell the pharmacuetical companies what kind of market share
they're going to get within our system so they can calculate how much money
they're going to make getting a drug onto our formulary and then we just
bargain with them straight up. There's really not a lot of backhanded deals,
under the table deals."
straight-up deals can be lucrative.
Incentives for Vioxx, according to internal Merck documents we've obtained,
gave 92% discounts to health systems putting Vioxx exclusively on their
formulary. The wholesale price for Vioxx is $324 a bottle. With Merck's
discount, it's just $27. That's almost $300 a bottle as incentive for health
systems to push Vioxx, despite the drug's warning of increased heart
Prescription drugs cost Americans $155 billion a year, rising twice as fast
as other medical costs. And the nation's health plan lobbying group says
insurers have to balance cost and benefit.
Pisano, American Association of Health Plans: "Get the best drug to people
when they need it but also to make sure that prescription drug benefits
continue to be affordable."
Albert Goldberg: "I have a business, I understand that there's a bottom line
and we have to be efficient but not at the expense of caring for our
agree in most cases: formulary problems are merely inconvenient, rarely
life-threatening. But consumers say they won't take it from their health
Adair: "Their interfering is interfering in medicine for financial gains."
California is among 15 states considering legislation to control health
plans and their prescription coverage. Health insurers argue they are
already over-regulated, but if they don't solve the growing problem with
formularies, consumers will demand government fix it.
California Dept. of Managed Health Care has an 800 number for complaints:
The California Patient's Guide: Healthcare Rights and Remedies