Normally, ordering a 3 month supply of prescription medication from Future Scripts (https://www.futurescripts.com/FutureScripts/), a subsidiary of Independence Blue Cross (https://www.ibx.com/index.jsp), was nothing more than logging in, clicking on what needed to be ordered, and then checking out. But just a few weeks ago, I noted that when I tried to do so by clicking the link https://portal.myfuturescripts.com/MyFutureScripts/mail_order_saml?redirectToMailOrder=true., I was informed that there was an error in logging into the site. Double checking the password was correct changed nothing. I called my family doctor’s office to have them send the prescriptions instead, and got a notification from Future Scripts that my order was being processed as well as a phone call to my home number asking me to verify my address (something I have never had to do before). I was given a deadline of August 31 at midnight to respond or the order would be canceled. I called and learned that the order had already shipped and the person who took my called was just as puzzled as I was that: a) I had gotten that call when everything about my order and shipping address was clear, and b) despite the need to confirm my address, the order shipped anyway before I called. She also informed me that it looked like Future Scripts was now going to be placing that same call with each order because my shipping address, as it has been, has been my office to assure that someone is present to get the order rather than have it sit in a hot (or cold) mailbox or be sent back if there is a signature required. I was further unpleasantly surprised to learn that Future Scripts was actually no longer administering my 3 month prescriptions because Independence Blue Cross had taken over that function. Moving forward, I would have to sign into https://www.ibx.com/index.jsp instead. I did that just to check and after a few false starts found that my Future Scripts password worked for that as well. I was also informed that Independence Blue Cross had NOT told its members of this change, and had instructed customer service to tell members who call Future Scripts to log into their website instead without providing any explanation about how such a change had been rendered without informing members about it. This in essence forces those who use the online ordering service to have to make a time consuming call to a toll free number, wading first through the irritating mechanical voice options asking numerous innocuous sounding questions that on a more sinister level seem designed to irritate and frustrate those who call. Sure, automated voice protocols save time and money for the company, but as with all things insurance related, more and more of the cost is shifted to us, the consumer/member/“covered lives” that these companies so depend upon for their existence. Just out of curiosity, I logged in again to Future Scripts mail order services today, but when I clicked the link noted earlier, this time I got a new message:
2020 Thank you for your interest in online pharmacy services. Our records indicate that you are not eligible for Pharmacy Benefits. If you feel you have received this message in error, please call the number on your ID card. Please refer to error code 2020.
I know I still have 3 month pharmacy benefits. The policy we have has not changed at all except to have gotten more expensive for the new year while offering less. I cannot imagine calling again to find out what I already know. What is troubling is that if I am getting that message, how many other people will be too and how many people will be sent into a panic as a result because of the information presented in such a message? How many phone calls to Future Scripts and/or Independence Blue Cross will that generate? One would think that such a change in pharmacy benefits management would have been made very clear to all covered members at the outset, but what incentive do they or any insurance company have to be proactive? Instances like these do nothing but promote the continued disgust and malice the public often feels toward insurance companies. During a time when premiums continue to increase for diminishing and more restrictive services and benefits, there is this to consider:
Thirty-three people who served as the CEO of a Blues plan for some or all of 2014 collectively earned more than $26 million in salary and about $102 million in total compensation, which includes bonuses, 401(k) retirement contributions and other incentives, according to data supplied by state regulators in response to The AIS Report’s Freedom of Information Act requests and other inquiries. https://aishealth.com/archive/nblu1015-01
The numbers were roughly the same in 2015 according to the AIS report for that year. http://www.streetinsider.com/Press+Releases/Despite+Flat+Salaries,+Blues+Plan+CEOs+Collectively+Earned+$102+Million+in+2014,+AIS+Newsletter+Reports/10931041.html
In 2014, Daniel J. Hilferty, the CEO of Independence Blue Cross, saw a 6.2% increase in his total compensation to nearly $3.8 million per year. I don’t begrudge anyone the opportunity to make a good, or even amazing living. In comparing Hilferty’s salary to that of a Hollywood star or a star athlete, it pales in comparison and would be considered modest. However, when one looks at the aggregate of all executive and board compensation packages across the insurance industry, it is quickly evident where the majority of the disposable income is going after accounting for usual business expenses – not to patient care. In 2015, his counterpart at UnitedHealth Group, Stephen Hemsley, received total compensation in 2015 of $14.9 million, David Cordani of Cigna – $14.5 million, Joseph Swedish of Anthem Blue Cross – $13.5 million, and Bruce Broussard of Humana – $10.2 million. George Paz of Express Scripts, a pharmacy benefits management company like Future Scripts, earned $12.9 million in 2015. http://medcitynews.com/2015/06/what-were-the-top-healthcare-ceo-salaries-last-year/
So where does this leave us as consumers, as physicians? As a doctor, I am constantly faced with challenges to my decisions, largely in the context of prescriptions and what insurers think is appropriate or “medically necessary.” I have written elsewhere about both prior authorizations and why generics not always a good thing, but it goes beyond that. I realize that there are finite dollars to spend and that cost containment is a sensible consideration in any industry or business. As a dramatic example, a person complaining of a headache should not automatically have a brain MRI, which is very expensive and most often overkill for what may resolve on its own with no consequences. As physicians we need to be ever mindful of listening to our patients and thinking about the problem(s) presented as opposed to knee jerk orders for testing and other consultations in the name of being “thorough.” Insurance benefit limits can serve as a reminder for that. However, the health insurance industry is unlike no other industry because the direct currency is human life, and insurers are continually translating, or converting, if you will, that currency into dollars. Decisions made are on an endlessly cycling ethical slippery slope and there seems to be little that can be done at present to stop that process. But that is not to suggest that we are paralyzed and can do nothing. Change is always inevitable, so it would be up to us to try to direct that change in a positive direction.
For change to happen, there would have to be a consistent and sustained effort that speaks the monetary language of insurance companies. Employers, as represented by their human resources departments, need to work on harder negotiations with insurance companies. The larger the employer, the louder the voice. Joining health insurance purchasing cooperatives is one way to enhance bargaining power. A health insurance co-op (consumer operated and oriented plan) is not a new idea, and some of the first such groups began to appear in the US in the 1990’s. Elliott Wicks of the Economic and Social Research Institute wrote about this in 2002 in an issue brief for The Commonwealth Funds Task Force on the Future of Health Insurance. (http://www.commonwealthfund.org/usr_doc/wicks_coops.pdf) In it he noted that at that time there had been a number of successful co-ops, but also numerous failures and he reviewed the various reasons for those failures as well as for the successes. One point he raised that was striking was this:
In the future, co-ops might be able to offer more attractive prices, but that would depend on reaching “critical mass” size. To offer attractive prices, a co-op has to be able to realize administrative savings and/or have bargaining leverage with health plans. Both these conditions require that co-ops control significant market shares
But he also realized that it is difficult to reach that “critical mass size,” and warned against co-ops becoming a vehicle for pooling high, medium and low risk employers because of possible “adverse selection.”
In 1995 there were at least nine states that had formed some type of health insurance purchasing cooperative (HPC) or alliance. By early 2009, there were at least 28 states with such cooperatives mandated by state law or regulation. The federal government has also been involved in the creation of co-ops. Indeed, one mandate by the government was that a co-op “must operate with a strong consumer focus, including timeliness, responsiveness, and accountability to members in accordance with regulations to be promulgated by the Secretary of HHS.” For a more in depth review of the current state of co-ops, I refer the reader to http://www.ncsl.org/research/health/purchasing-coops-and-alliances-for-health.aspx.
While I think co-ops are a valid concept, it seems that a number have failed, though many continue to exist and do well. The bigger issue we face is the amount of power wielded by insurers. Who is regulating them? Among insurers, for 2016 Blue Cross/Blue Shield contributed the most money to political campaigns and parties at $6,555,994, while the total for the insurance industry for 2016 thus far has been $75,672,091. https://www.opensecrets.org/lobby/indusclient.php?id=F09
During the 2012 election cycle, the insurance industry contributed a record $58.7 million to federal parties, candidates and outside spending groups https://www.opensecrets.org/industries/indus.php?ind=F09
While a discussion of PAC’s, lobbying and campaign contributions is beyond the scope of this essay, the point here is clear. The language of currency is universally understood and is perhaps the most effective form of communication, which is how insurance companies have been permitted to use loopholes such as ERISA (see a previous blog entry) and avoid litigation as well as more definite federal and state control of how they operate. The net effect has been a good enough immunization against social forces or consumer discontent that might otherwise ultimately force a change in restrictive processes such as prior authorizations, dosage limitations and other forms of treatment denial. The argument on their part has always been that they are not denying treatment, but rather refusing to authorize it, which means it will not be reimbursed. Again, currency is the loudest and most effective voice.
Perhaps, though, there is hope kindling at present. As I have reported elsewhere, litigation against insurance companies is beginning to become more commonplace. For instance, there is the lawsuit in New York against UnitedHealth Group for violation of mental health parity laws. And more recently, United States Attorney General Loretta E. Lynch recently announced that the federal government, in an effort to ensure competition and fair pricing, is suing to block the proposed Anthem Blue Cross-Cigna and Aetna-Humana mergers. Listen here as Bill Baer, the Antitrust Chief of the Justice Department, explains what is happening: http://www.nytimes.com/2016/07/22/business/dealbook/us-sues-to-block-anthem-cigna-and-aetna-humana-mergers.html?_r=0
UnitedHealth Group had announced in April it was pulling out of the health insurance marketplace established by the Affordable Care Act (Obamacare). Humana and Aetna more recently announced the same intentions. All are claiming financial losses because individuals who might not otherwise have been insured are getting insured and tend to be sicker, according to reports, which means more money HAS to be spent on patient care, driving down corporate profits. Is a CEO seeing a total compensation of over $10 million really going to feel that? Perhaps – it’s not for me to say. But crying poor all of a sudden because a company has to do what it was originally intended to do – insure people for health care coverage – is ethically sickening.