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Doctor Steps into Patient's Shoes to Deal with Insurance Company

The experiment took thirty-three minutes and forty-one seconds. That’s about the time it takes to see a new heart-rhythm patient or implant a defibrillator.

I was just curious. I wanted to dip my toes into the icy waters which so many primary care doctors have already acclimated to.

A denial? Are they kidding. That medicine fits this patient perfectly. The entirety of cardiology agrees, and so does the FDA, which isn’t always the case in cardiology – take defibrillators for instance.  (But that’s another topic altogether.)

So I called the long-distance number listed on the denial letter.

…For providers (Argh)…push ’2′, said the computer message.

For a while I played along with the automated message, but it wasn’t long before I was jamming the zero button trying to get a human to answer.  Six zeros later came the friendly voice. Finally. She was in Pennsylvania; the patient and I were in KY.

Now we are up to 9 minutes. After a few introductions she asked for the member’s number.  Member?  You mean the patient, right.

…Let me connect you to your “local’ agent.

Back on hold I went.  Ten minutes later a another friendly voice answers.

I ask: “What’s up with this denial thing?” While I think: “Hello, do you all know I am a cardiac electrophysiologist.” Though I am certain: they don’t care who I am.

From the friendly local agent, I learn this particular health plan automatically denies all new drugs.

Snarkily, I ask: “What if the drug cured Cancer?”

Calmly, the voice responds: “It would still be on a moratorium. Would you like to talk with one of our medical people?”

“You mean you're not a medical person?  Sure have them call me.”

I was surprised when a few minutes later a clinical pharmacist called me back. Pradaxa was awaiting approval from their Pharmacy and Therapeutics committee, he said. They meet in a month or so. “We have a few local docs on the committee.The primary issue with this drug is that it costs more than warfarin.” Duh!

So there you have it.

Cardiologists agree on Pradaxa’s benefits. So do the epidemiologists and statisticians.  Mathematicians can demonstrate that the upfront costs of the drug are more than made up by its superior efficacy in stroke prevention and reduced bleeding in the brain. Even the FDA gave the drug a unanimous two thumbs up.

But patients on this local KY health plan await the decision of a few local docs and pharmacists.

Double Arrgghh!

When the accountable care organization comes to town, I want to try-out for quarterback, obviously as a walk-on.


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