New Healthcare Plans and Our Dysfunctional Medical System ... Urgh!

Sooner or later, I suspect that almost everyone is impacted by the rising cost of healthcare. The U.S. has an estimated 47 million uninsured, and a large number of underinsured people. In fact, Families USA, the national organization for health care consumers recently released a 50-state survey, which revealed that insurance companies in most states are not prohibited from denying health coverage to people with pre-existing conditions, refusing to pay for services needed to treat common ailments, adding huge premium surcharges for people with family histories of health problems, and yanking policies and denying payments when consumers face a rash of medical bills. The issue has grown so large that today, even Federal Reserve chairman Ben Bernanke commented about the subject in a lengthy diatribe on this matter. Fortunately, I am not one of the un- or under-insured people, but that doesn’t mean rising healthcare costs don’t affect me. Unlike when someone changes a job and they can anticipate certain changes, occasionally, the cost issue forces itself upon us. For example, on June 1, 2008, my employer switched to a different healthcare plan. The new provider (Empire Bluecross/Blueshield) made them a deal they simply couldn’t refuse, so my coverage with Oxford/United Healthcare ended. Of course, such changes can create a degree of confusion for anyone, but for those of us with diabetes, the changes can be particularly burdensome, and I didn’t really have a choice in this matter.

The first issue is the little issue of compliance with the various policies imposed by our healthcare plans. Most healthcare plans give significant financial incentives to use mail-order pharmacies which they own outright or else contract with, so ordering 90-day supplies is the norm. My 90-day supply happened to be finished on May 30, so this time I was caught in the neverland of not being on the computers of my new healthcare plan on June 1, even though I was pretty close to running out of insulin by then. Fortunately, I was not removed from my old plan’s computers, so I was able to order a 90-day supply from Medco on June 3, even though I knew that I was no longer covered, but I didn’t have the luxury of waiting around for someone to enter me into the new plan’s computer – I figured I’ll eventually be billed in full for this life-sustaining substance, at which point I’ll submit it as a claim for my new plan. Although I don’t know whether my brand of insulin is one of the new plan’s “preferred brands” on their formulary or not, I simply don’t have the luxury to wait for logistics to be resolved, and in this case, its Medco who will be waiting to be paid, not me. But I could have been stuck buying the stuff out-of-pocket while bureaucratic systems get us member ID numbers and all.

For people with diabetes, plan changes are also about more than just whether our doctors are on the new plan, but the manner in which we live life from day-to-day is also impacted in a way that I suspect the average person fails to appreciate. Cash in point: pharmacy benefits manager (PBM) coverage, which my life quite literally depends upon. Unlike people who use medications to manage the symptoms of a condition, most people with type 1 diabetes would quickly go into DKA which can be fatal without insulin, so its not simply a matter of following doctors orders, or alleviating symptoms, but its about survival.

My old plan used Medco Health, whereas my new plan uses Caremark. Aside from any changes in formularies (for example, my old plan considered Lilly insulins to be “tier 3”, their most expensive, and essentially encouraged the use of “preferred” brands from Novo Nordisk or Sanofi Aventis). I’m still waiting for the formulary on my new plan to determine which brand products are the “preferred” brands, but it looks like the new plan is very similar, except they might actually cover Lilly (or is that Hospira?) insulin as a “preferred” brand.

Anyone whose very life depends upon an external source of insulin knows this isn’t simply a brand switch; there are often legitimate differences in the time-activity profiles associated with each insulin brand, and I may require additional testing to make it through the transition – safely. Will my new plan cover the cost of any extra supplies needed? Probably not, but realistically, they should as part of landing the account, but in the dysfunctional U.S. healthcare system, the burden is placed on the patient, not the healthcare plan.

Then there is the matter of “in-network” vs. “out of network” physicians. In my case, my PCP (primary care physician) was “in-network” under both plans, but my endocrinologist is not. However, I tend to view this as an opportunity to find a new endo whom I might like better – my old endo was convenient, but it took forever to schedule an appointment and the staff at his office could occasionally be a bit rude. Incidentally, I’ve found a new endo, someone I met a few years ago at the ADA Scientific Sessions and his office is only a few miles away, and even better, he’s seeing new patients who are not pediatrics, so I don’t think I’ll be traumatized since I’ve had the chance to meet many great physicians over the years (having relocated including 2 cross-country moves over the past 20 years, I’ve become used to change). Others, however, might not be as flexible or optimistic about the situation as I am.

Now, when Americans call the U.S. “the best healthcare in the world” I often wonder how many other countries’ healthcare systems they’ve ever actually sampled? For example, in 1987, I lived in Finland for a while, and I can honestly say, their healthcare system blows ours away! But many defenders of the current U.S. system often have never even left the confines of their own state, let alone left the country, and I wonder what life would be like to be so incredibly naïve about the world.

Anyway, taking all of this in stride, I’ve actually found a way to take advantage of this situation. For example, I need new prescriptions for everything: test strips, insulin, pen needles, syringes, an ACE inhibitor … everything, so I’ve asked my PCP to write these for me so I do not run out before I can meet my new endo. Since I just fulfilled my last 90-day order about 2 weeks ago, I will be placing another this week, so I will likely be getting about 180 days worth of supplies all at once. Not that I won’t have to pay for it, I’ll have to deal with claims for my order with Oxford/Medco sooner or later, but in the meantime, I won’t be running short of supplies! I am also using the opportunity to take advantage of differences in policies, such as the fact that my new healthplan does not appear to require doctor authorization to exceed an arbitrary number of test strips used each month. I wish others could walk away from this type of situation as positively as I have!

Hi, Scott, thanks for the welcome! I’ve been managing alone for so long, it’s going to change my world to be able to compare notes with others. Look forward to sharing with you and everyone else at Tu diabetes. I hope you get a chance to visit my blog ( where you’ll find out a lot more about me. I discovered your site several months ago, and put a link to it on my blog when I started it.Bye for now-- Mike