Friday, December 15, 2006

5 Phone Calls to Get Prescription Partially Filled

President Bush’s health care vision involves educated patients making purchase decisions. This means being able to negotiate one’s way through the health care maze and its provider/insurance bureaucracy. My late afternoon experience might burst this bubble for many.

My primary care doctor is treating me conservatively for a shoulder injury, a possible rotator cuff tear. He started me off with medicine and physical therapy. Just yesterday I had an MRI on my right shoulder and seeing the Celebrex samples would soon run out, I called the office for a prescription.

This afternoon I called the pharmacy, hopeful the doctor called in the script. While he’d done his part, my pharmacy benefits manager (PBM) put a hold on filling the prescription. Apparently they needed more documentation before approving its dispensing. So I dialed the doctor’s office to find they’d already gone for the day. Both the pharmacy and the clinic told me I’d have to wait until next week to get the drugs that would reduce swelling inside my hurt shoulder.

Not satisfied I called my PBM to complain. The Medco representative heard me out and to my surprise gave me the number of the Prior Authorization Department. Kwame instructed me what to do when I reached that automated attendant. It got me to Jackie who started the authorization from her end. She contacted an internal pharmacist who approved a 4 day supply of the medication. I called my local pharmacy back to explain Medco’s change of heart.

After 5 phone calls I got enough medicine to get me through the weekend. How many people would have given up after the first or second call and just gone without? The studies on low medical literacy in the United States translate into few people successfully navigating the system to get their needs met. I think this is what insurers count on.

Bush’s projections of declining demand for care is more likely health needs going unmet in the future. I had to make 1.25 phone calls per pill just to get my weekend medication need met.

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