By Don McCanne, M.D.
September 17, 2018
In the big picture of health care in America, the following anecdote is quite trivial, but, as I’ll explain, the implications are of great consequence.
Through the years my wife and I have had great care coordinated by our highly competent primary care physician. He retired recently and his practice was taken over by another physician. I needed a refill on my two blood pressure medications, but rather than interacting with the physician, I was now interacting with OptumCare Medical Group, a subsidiary of UnitedHealth. (You’ve no doubt read about insurers consolidating with physician groups – it’s very real.) Although we have avoided the private Medicare Advantage plans, I found by perusing OptumCare’s website that, without my knowledge, I was assigned to their Medicare Pioneer ACO.
The trivial complaint of mine is that I had to have numerous contacts through an always-busy telephone system and a non-responsive contact point on their website which resulted in many days of effort just trying to get my two basic blood pressure medications refilled. Several errors were made and, in fact, they never were correct even after repeated attempts. The prescriptions had the names of two different nurse practitioners on them, and finally one had the name of my new primary care physician after I was finally able to see him. Part of these glitches were due to the fact that they were transitioning to a computer system.
Not only were my prescriptions under the control of OptumCare, I was also covered by a Part D Medicare drug plan through Anthem Blue Cross. All I wanted was a 90 day supply of each pill with 3 refills, just as I had had under our previous physician. Well, somewhere between OptumCare and the Anthem drug plan, our independent pharmacist of many years was authorized to fill only a 30 day supply, but for only one of them since it was too early to fill the other one. This meant that I would have to come back every 15 days indefinitely to pick up only one prescription at a time. I checked the Anthem website and found that not only was my pharmacy not on the preferred list, it was no longer listed in the Anthem network at all (with a statement that pharmacies could be changed at any time without notice).
I discovered that I could receive 90 day supplies by mail through Anthem’s pharmacy benefit manager, but it seemed unfair to me that they should take over the bread and butter trade of easy long term prescriptions while leaving the local pharmacist with the need to carry a huge stock of a great variety of prescription items that are filled usually only once, creating an overhead headache without a volume offset.
I finally gave up. Since I still have my medical license, I ordered stock jars of 1000 pills each through a medical supplier so I wouldn’t be bothered with the hassle any more (a strategy not available to most people). Of course, that’s not covered by the Part D plan, but I had had enough. (I should mention that though it is unethical for a physician to prescribe for himself, these two medications were actually prescribed by my primary care physician and by my cardiologist.)
Yes, this is very trivial compared to some of the horrendous problems that others face in our health care system. But it is what this annoyance represents that is so objectionable. The system should work so that I can get my very common, tier one generic medications every three months with an effortless system of refilling them. Instead, my physician has been hijacked by one of the largest insurers in the nation, and my pharmacist has had barriers erected by another of the largest insurers, together making it much more difficult for me to obtain my straightforward maintenance medication. What value are these giant insurers adding that we should have to tolerate their inanity?
The reason that everyone should be concerned is that this takeover of health care is expanding rapidly, with no relief in sight. If it doesn’t work well for minor routine matters, how could it work well for the big stuff? A well designed, single payer improved Medicare for all program as is advocated by Physicians for a National Health Program would solve most of the problems with our highly dysfunctional health care financing system. Although there is widespread public support for such a model of reform, look very carefully at what is actually happening in the political arena.
Congress and the administration are continuing to expand the private Medicare Advantage and private Medicaid managed care models. They are continuing to push alternative payment models including accountable care organizations and other so called value-based proposals that involve intrusions by insurers and other managers. While using the Medicare for all rhetoric, they are quietly suppressing the bona fide single payer model while giving the business intermediaries an even greater role in (mis)managing our health care system.
HR 676, the Expanded and Improved Medicare for All Act contains many of the principles of a well designed single payer system. People are enthused to see the formation of a Medicare for All caucus in the House. There has also been considerable enthusiasm over the introduction in the Senate of Bernie Sanders’ bill, S 1804, as supposedly being a single payer Medicare for All bill in the Senate. However, to gain cosponsors, many compromises were made. Exemplifying them is the inclusion of the following:
“Sec. 611 (b) Application Of Current And Planned Payment Reforms.—Any payment reform activities or demonstrations planned or implemented with respect to such title XVIII as of the date of the enactment of this Act shall apply to benefits under this Act, including any reform activities or demonstrations planned or implemented under the provisions of, or amendments made by, the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114–10) and the Patient Protection and Affordable Care Act (Public Law 111–148).”
This means that the payment models of ACA and MACRA with MIPS and APMs including ACOs would be perpetuated under S 1804. What is especially alarming is that members of the House Medicare for All caucus, instead of protecting and supporting the single payer features of HR 676 and encouraging the Senate to endorse the same, they want to change HR 676 to include the highly flawed features of S 1804. It appears that the intent of Congress is to perpetuate the entities that are creating many of the very problems that we are trying to solve with PNHP’s version of an improved Medicare for all. Leaving our dysfunctional system in place while merely adding a Medicare Advantage-style public option is no solution at all.
My wife and I have transferred our care to another excellent physician. We left OptumCare but are continuing with the traditional Medicare program with a Medigap supplement to protect us in the event of catastrophic events. We also are continuing with our Part D drug plan to protect us against the potential of those $100,000 drugs that are becoming so commonplace. But wouldn’t it be nice to have the Medigap benefits and the drug benefits rolled into the traditional Medicare program along with the other improvements that would be ideal in an improved Medicare for all? We’re not going to have that unless we start communicating more effectively with our members of Congress, even if it means using our boot.
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