By Virginia Gebhart
Daily Camera (Boulder, Colo.), Oct. 13, 2016
You’ve seen the countless ads on TV, sponsored by Coloradans for Coloradans. This is the opening line, “Sometimes too big can be bad.” I agree. I invite you to think about who is too big.
Is it ColoradoCare or is it an insurance company (Anthem, valued at $27 billion) and their pharmacy benefits manager (Express Scripts, valued at $59 billion) who continually, year after year, shift more and more costs to customers while making it harder every year to access care and prescription medication?
My son, Michael, is a liver transplant recipient. He takes anti-rejection medication that is expensive, about $600 per month, retail. Yes, it’s generic. He takes another anti-rejection medication that costs about $20 per month. Any pharmacy in the state of Colorado could fill these prescriptions with a few days’ notice. Yet Express Scripts declares that the expensive medication must be obtained from a specialty pharmacy in the state of Rhode Island. Their specialty seems to be the worst customer service in the history of the profession of pharmacy.
Michael has spent hours and hours and hours on the phone trying to understand and fulfill their requirements for a prior authorization for his anti-rejection medication that he has taken for nearly 10 years and will need to take for the rest of his life. Not surprisingly, it’s only the expensive medication that requires a prior authorization and procurement through a specialty pharmacy. His co-pays go up every year. Suddenly this year, he gets only a 30-day supply, so he pays the co-pays monthly, not every three months as in the past. Early this year, the co-pay was $80 per month for his expensive medication. Suddenly in August the co-pay became $500 per month. We don’t really know why and neither do the pharmacists at the specialty pharmacy. Michael got them to admit it was a mistake in August, but they charged the same $500 again in September. So apparently he’ll have to spend hours on the phone each month to get them to charge the correct co-pay.
Or not. Maybe he’ll just have to pay $500 each month going forward. He would have a rejection episode if he stopped taking his medication. At best, he’d land in the hospital, which would cost many thousands of dollars. At worst, he’d die. Who knows what he will have to pay next year? We know his insurance premiums will go up about 25 percent, but we don’t know what his deductible will be, nor his prescription co-pays.
Michael can’t understand why his insurance company makes it harder and harder each year to get his prescriptions filled. As a retired pharmacist, I understand very well. Insurance companies and pharmacy benefit managers have been shifting more and more costs to their customers for over 30 years. It gets worse and worse every year. I explained to Michael that there are two reasons for these immoral business practices which ought to be illegal. The first reason is that they know that as customers must pay more and more for their medications and the process for filling prescriptions in network (i.e. mail order) becomes more and more onerous, people will give up and just go to their neighborhood out-of-network pharmacy to fill prescriptions and pay full price out of pocket.
The second reason is that they are trying to drive him away. They hope he will get fed up with Anthem and search for a different insurance company, hoping for better coverage and service elsewhere. They don’t want him for a customer. However, Michael has learned that the pharmacy benefit managers like Express Scripts who command huge market share across the country are racing to the bottom together to provide the same inadequate coverage and terrible service to customers like Michael who have the bad manners to actually need health care and medication.
So you tell me, who is too big? Is it ColoradoCare, which will have the ability to shift away from perverse incentives that result in inadequate coverage and terrible service? Or is it Anthem (CEO compensation in 2015 was $13.6 million) and Express Scripts (CEO compensation in 2015 was $14.8 million)? Is it ColoradoCare that is too big, or is it Anthem, which has donated $1 million to defeating ColoradoCare?
Virginia Gebhart lives in unincorporated Boulder County.