Pharmacy Frustration

ABC News reported recently Mississippi. Lawmaker Suggests Woman Buy Daughter's Diabetes Meds After She Writes for Help. This constituent wrote to her state representative and expressed concern and upset with receiving assistance from Medicaid for her daughter.

The mother expressed her perception that “that children with Type I Diabetes ‘aren't getting the necessary diabetes supplies and meds they need to stay healthy.’" The constituent’s daughter is eight years old and suffers Type I diabetes. The more publicized diabetic condition, Type II, results from a variety of factors. Type I is a result of systemic failure and often affects youth (often it is called "Juvenile Diabetes").

The constituent reminded the state representative that supplies and medication for diabetes are “explicitly stated as a covered benefit" under Medicare/Medicaid. She complained that difficulty and delay in obtaining these items puts the patient at risk, saying “the essential diabetes supplies (are) needed, not only to keep our kids healthy, but to literally keep them alive,"

Her representative responded and apologized that the mother was experiencing issues. He questioned “have you thought about buying the supplies with money that you earn?" This reply did not go over well, and the mother described herself as “filled with "'silent fury.'" She responded and provided an overview of what diabetes medication costs; she estimates it is about $2,500 per month, almost $100 per day.

Coincidentally, or not (there is support for the notion that Type I diabetes can have a genetic component), this constituent’s husband also suffers the disease. She noted, however, that “he has not had any problems receiving medication, which is covered by his insurance through his employer.”

What on earth does this have to do with workers’ compensation? A major complaint that I hear regularly involves workers’ delay and hassle in getting medication. This includes authorization issues, refill issues, and convenience issues.

In the authorization issue, people complain that they visit the doctor that the employer/carrier has selected. A script is either handed to them, or increasingly transmitted electronically to a pharmacy. When the patient arrives at the pharmacy, however, the script is not ready to pick up. The staff explains that they have called the workers’ compensation adjuster to seek approval (an agreement that the pharmacy will be paid), and that they are awaiting a return call.

In the refill issue, there are similar authorization complaints expressed. But, more often the complaint is that refills do not necessarily match the patient’s understanding of the physician’s advice. This is less prevalent when the instructions are to take one pill each morning and one each night. In the definiteness of that set of parameters, it should be reasonably easy to calculate how long "x" pills will last. But often, physicians are not so definite, and the prescription provides some leeway or discretion for the patient ("as needed," or something similar). The patients complain that refills are denied or delayed based upon some insurance carrier rule or guideline or belief about how long a medication refill should last.

The convenience issue often regards refills as well. A claimant once described to me that a primary care physician had prescribed a 30 day course of mediation. Within days, the worker was blessed to get an appointment with a specialist, who added two new prescriptions. Filling those two required a few days due to authorization issues. And within two weeks, the worker was seen by a second specialist, and a fourth medication was added to the regimen. All four were thirty-day scripts. The effect, however, was that this worker had to visit the pharmacy on an almost weekly basis each month for refills, because the three thirty day periods did not have the same conclusion.

Are these real concerns? I cannot say because I am not a workers’ compensation patient travelling to the store for medication. But, each has been related to me enough times that I conclude there is some truth to the issues. Certainly, I can see the frustration for the patient when deadlines (for refills) occur on different dates. Certainly, I can see frustration when the pill bottle is empty and the patient can neither get it refilled nor get any real explanation. And, I can see the frustration of multiple trips each month to the pharmacy. 

In Florida, the injured worker has the right to select his or her own pharmacy, and that can be a real benefit. I have an acquaintance who uses medication persistently, provided by group health. He explained to me that his health insurance company uses a pharmacy benefit manager, or “PBM.” Due to an acquisition, his PBM changed. As a result, he was not permitted to use his long-time pharmacy (less than a mile from home) and had to use a store in the carrier network, which was miles in another direction, and not convenient. At least in workers' compensation, there is not this added inconvenience?

In terms of delivering service to the injured worker, is there a way to decrease the hassle of multiple monthly pharmacy trips, speed authorization of routine refills, and enhance communication between the patient, the medical provider and the pharmacy? And from the original point of the mother that inspired this post, is the solution really just buy the medicine yourself?  I am dubious that this is the appropriate response.