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by Elissa Ely **
Boston Globe (June 11, 2011)
EVER AN unwelcome guest: the pharmacy review letter. This one said that the patient, whose name and birth date headed the page, would no longer be covered for name-brand medication he had taken for years. He had a new Medicare Part D insurer, whose formulary carried only generic.
Neither the patient nor I knew he had a new insurer, but we had gone through the details of his medication incompatibility many times with the old insurer. When he took generic pills, he became nauseated and dizzy. Then he grew disgusted and stopped the medication altogether. Then he was hospitalized.
In the end, a more expensive brand was cheaper than another inpatient admission. Prescribing it required submitting prior authorization paperwork to the old insurer each year; the same questions were asked and the same answers given. This exchange had just occurred a month earlier. We were expecting to be left alone when the letter arrived.
“If you decide an exception request is appropriate,’’ said the letter, “contact us by mail, by fax, or by telephone.’’ I dialed the phone number. After a few firm operators, the pharmacy review representative came on. I told him I would fill out any prior authorization form necessary, but each insurance company uses its own template. Would he please send me theirs?
The representative asked for the patient’s insurance identification number. I looked at their letter. There was no identification number on it, and we of course had none, since we had not known he had new insurance.
I did however have his name and date of birth. The representative took them, and put me on hold.
Hearing interim music over years, captive and waiting, one develops certain distrusts. The likelihood of being disconnected is directly proportional to the amount of time spent listening. You must find a way to listen without listening; a koan that cannot be answered.
I tried to listen without listening until the rep returned. He had bad news. Based on the name and birth date, this patient did not exist in their database. That meant they could not send the form that needed filling out, which meant the name brand med could not be prescribed. It was an impediment to the deterrent they had already raised.
At this point, a visitor from another planet, sent to assess our heath care coverage system, might wonder. If a patient doesn’t exist, how does his insurance company send a letter denying him meds? Maybe an alien civilization could follow the logic.
The pharmacy review representative had no answer. I had no answer. The patient, who existed in actuality but not on paper, had no answer and soon, would have no medication. This left the interplanetary visitor to explain. While he was considering, there was nothing to listen to except silence.
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** Elissa Ely is a psychiatrist.
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