60% Good News

03.21.11

This morning the news I got was 60% good. After posting about the problems with getting my prescription now that CVS Caremark is administering our prescription coverage I got some really great advice from my readers.

I started with a very long phone call to my State Insurance Commissioner. During the phone call they detailed for me the process of filing a complaint, which begins with contacting the plan administrator. The plan administrator was extraordinarily kind. So much so that when I detailed the series of events I ended up crying. It was the first time anyone had been remotely sympathetic to me.

The plan administrator called me back promptly on Friday and left a message letting me know she had an update, but I wasn’t home all day Friday so it wasn’t until this morning that I was able to return the phone call.

The Plan will reimburse me 60%. I will get approximately $1,200 back, and the other $800 or so dollars will be mine to pay. I will continue to use the mail order pharmacy or be required to pay cash (which is not really an option).

I’m not sure if I should be happy with this. $800 is a lot of money to pay, but $1,200 is a lot of money to be reimbursed. I’ve spent nearly 20 hours on this, and I’m not convinced that 20 more hours would get me the $800 that I feel is due to me.

What I do know is that insurance isn’t designed with health in mind. If it were then physicians would be able to prescribe patients the best drug for their disease and patients would have immediate and unfetterd access to the drugs that can arrest their diseases. Rheumatoid Arthritis is not the common cold. One third of RA patients end up on disability within a few years of diagnosis. That number is a number that has been steadily dropping due to the discovery and manufacture of biologics like Simponi (the one I take), Enbrel, Humira and Orencia. These are not inexpensive medications, but they are far more economical than visits to specialists for pain relief and (sometimes permanent) disability.

No one can tell me that our current system makes fiscal sense.

My readers (bless you all) have been so kind and helpful, emails have detailed for me how to work within the system. Until last August I never understood that a system existed, and I worry terribly for people who would have to wade through telephone trees and piles of paperwork all the while feeling ill and trying to keep their jobs. It’s simply unteneable.

Again, I’m not sure if this is where it ends for me, or if I take the next (rather exhausting) step and bring civil action.

I have been in contact with the mail order pharmacy and I was left speechless when the operator (pharmacy tech possibly?) was unable to pronounce simple words. After I listed the drugs that I am allergic to I waited for him to ask me what prescriptions I’m currently taking. The question didn’t come. Someone other than CVS will have to protect me from the possibility of a drug interaction, a real pharmacist perhaps.

I’m sure I’ll be okay because I have an amazing local pharmacist and a two of the most talented and devoted physicians a patient could hope for, but it will be in spite of CVS’ mail order pharmacy, and not because of it.

 

Changing Doctors

12.15.09

When I was pregnant with Jane we interviewed pediatricians. While sitting in one of the offices I felt a little familiar with the pediatrician. I couldn’t quite place the face, but then he and I both realized that I had been his patient many years ago.

From my daughter’s birth in 1998, through 2005 My Pediatrician was my children’s pediatrician. The care they received was top notch. The office, was not. The office started with screeching and wait times were at a minimum an hour, sometimes more. One day, as I sat in the waiting room it dawned on me that I could change doctors. Immediately.

It wasn’t an unemotional decision. The man who had kept me in good health, the man who I’d trusted and who had cared for my children would no longer care for them. I didn’t feel good about going elsewhere. And then we got there. We got to the new pediatrician and appointments were honored, they didn’t triple book. The office was kind and not screechy. Medically it’s the same for my kids. Both places are excellent, but only in one were they kind.

When my son was five months old I finally admitted to myself noticed that his eyes were crossed. Volumes could be written, but the punch line is that he immediately started wearing glasses, each eye was patched for several hours a day, and the diagnosis was strabismus and amblyopia. After a few months it became apparent that my son required surgery. As the doctor was telling us about the surgery, I kept hearing that he had trained under Dr. Cutter (not his real name, don’t bother googling), and my husband and I decided to go directly to the source.

At ten months old and then again at 18 months old my son had surgeries on both eyes. Dr. Cutter was masterful and my son was given the gift of vision. I am forever grateful to him for that. When I think of people who have changed our families lives, I think of Dr. Cutter. My heart swells and my eyes water. That is why leaving the office is so difficult.

Dr. Cutter is working reduced hours now. Yesterday my son had an appointment with Dr. Cutter’s associate. We arrived at 3.45 for our 3.45 apointment. At 4.30 when we were still waiting I went to the desk to reschedule, and stood next to a woman who was leaving. She had been there with her two children since before 2.00 and still hadn’t been seen. I asked the office to reschedule us, we’d come back on a less busy day. They offered up February 6th.

My son turns 9 in July. You get the first 9 years to correct these problems, we can’t wait, he needs the doctor. He has one, maybe two exams left before the clock ticks and time is up. I have to take care of my son, and feeling cannot be part of the decision.

Next week we will return to the doctor we saw in Alexander’s infancy. He does less in the way of surgery, but the office is convenient and the wait times are reasonable, if at all.

I left Dr. Cutter’s office with a knot in my stomach. My son had been there weekly for the first few years of his life, and then regularly thereafter. Alexander learned to walk in those hallways and our exams went from infancy to childhood, from finding the toy to identifying the letters. We had a red glazed donut in the Doctor’s lounge after every exam where his pupils were dilated. Every time. We almost looked forward to it, Alexander and I.

My son grew up in that office, and now it’s time to leave. I find it extraordinarily painful.