The much touted goal of “consumer driven” health care ends up being people struggling alone through an incredibly complex set of rules and fighting with a private insurance industry that has every incentive to make the rules as confusing as possible so you end up paying more than you should. Over at the New York Times, Charles Ornstein has a good story about getting his child’s prescription filled. What makes great is how boring common this is. From the NYT:
Pam, the first customer service agent with whom I spoke at my insurer,Oxford Health Plans, a division of UnitedHealthcare, told me that it looked as if there was a mistake with the refill, and that I was entitled to a $15 refund. She gave me a tracking number and told me to call back in two to five business days.
Dutifully, I did so, and talked to another agent, named Mike. He told me that there had been a mistake, but that it was with the first prescription. The co-pay should have been $30, not $15, but as a courtesy because of its error, the plan would not seek to recoup the money. The baby’s prescription was on a higher-cost tier because it was for granules of the drug, essentially a powdered version, and not for tablets, which are in the lowest-cost tier.
But a look at Oxford’s website and at its drug list, also known as a formulary, revealed that Montelukast is listed as a Tier 1 drug, with the lowest cost. No distinction is made between tablets and powder.
Ornstein’s advice if you have a problem is to track all your health care actions, carefully check your insurer’s website, call your insurance plan, and ask to speak to a supervisor. If that doesn’t work then contact a health advocate.
This advice isn’t bad considering the current reality but it shows what consumer-driven health insurance means in practice. It is often making sick people or their families spend hours making sure you aren’t getting ripped off. The hours spent fighting makes it not even worth it sometimes.
Bringing this dynamic to a much bigger scale is the glorious future many Democrats and Republicans see for our health care system with plans to make everyone switch to buying individual policies on exchanges.
Photo by keepingtime_ca under Creative Commons license