Saturday, January 13, 2018

The Successful Patient: The Importance of Continuity of Care


In Minnesota during the last year we've witnessed a major medical insurance company, Blue Cross Blue Shield of Minnesota, wrangle with a major provider of medical care for children, Children's Hospitals and Clinics of Minnesota, a highly respected medical facility known for treating the toughest cases. The dispute between the two was about money. This dispute resulted in them parting ways, leaving about 60,000 BCBS patients without in-network care. Of course, they could continue to go to Children's Hospitals and Clinics and to the same physicians, but they would be required to pay more because this provider is now out of network for BCBS. Parents of sick kids now must face exorbitant medical costs alone or change providers.

There are other excellent pediatric medical providers in Minnesota. That's not the point. What is at stake here is continuity of care.

What do I mean by continuity of care? Let's look at an example. I'll use my experience. During the last four years, I've had nearly as many medical insurance plans covering my medical expenses. Every time I've been forced to change plans, I've been very careful to make certain that all my doctors, clinics, and preferred hospital are in-network providers for the new medical insurance plan. I've been going to my primary doctor for about 20 years. She knows me, knows my medical history, and because she has that knowledge I don't have to explain my medical history every time I see her. She also knows the best way to treat any medical issue I might have, and also knows the best doctors to refer me to for a specialist. It is much the same with the specialists that I see -- I've been going to them for a significant amount of time and they know my body and my health status. Keeping all these doctors in-network provides me with continuity of care.

If I were to be forced to change my doctor because a medical insurance company has that doctor out of network, then I lose that doctor's knowledge about my body and my health. I lose continuity of care. There may be other perfectly competent doctors in network for the medical insurance company, but none of them have the knowledge about me, the experience with me, and my health that my doctor has. That kind of knowledge and experience saves time and money in the long run.

Medical insurance companies look at me as a "loss" because I have one or more chronic conditions and will be making more than one or two claims during the year, as well as buying more than one medication. Medical insurance companies really don't want me on their plans because from their perspective, my claims are lost money to their bottom line. And no matter whether a medical insurance company claims they are nonprofit or not, they are all in the business of making a profit.

Because medical insurance companies only consider the financial side, they don't give a hoot about continuity of care. Has your medical insurance company dropped medications from its formulary in favor of other medications that are cheaper? One of the things pharmacy benefit managers for insurance companies will do is require that a patient use the formulary medication to see if it will be effective (and they will save money). They do not make this "suggestion" after consulting with a patient's doctor to find out if the doctor concurs. They tell the patient and the patient's doctor that this is what they must do, effectively telling the doctor how to practice medicine (although insurance companies take care to state on their websites and in the printed materials that they do not practice medicine. The way they conduct business becomes, in effect, practicing medicine -- and without a license.).


Last year, for example, my medical insurance at the time dropped one of my medications from their formulary. I'd been taking the medication for 8 years and it had been extremely effective for the condition I had. Continuity of care would say that I should remain on that same medication and not make any changes. My doctor submitted a prior authorization request for that medication, call it Med A. The pharmacy benefit manager denied the request and the reason was that I had not tried Med B, used to treat the same condition and about $150 cheaper per month. So, my doctor prescribed Med B which had a step up dosage, i.e. I took 1 pill per day the first week, 2 pills per day the second week, 3 pills the third week, and the full dose of 4 pills the fourth week and every week thereafter.

Immediately on one pill per day, I experienced severe side effects: dizziness so bad I couldn't stand up for very long, nausea, balance issues, increased pulse rate, runny nose, and frequent urination. I missed a day of work as a result. The second day, the side effects had diminished but were still with me. I powered through. When I increased to 2 pills per day the second week, that's when the allergic reaction began on top of increased severity in the side effects: itchy throat, itchy bumps in my throat, sneezing, runny nose, and increasing fatigue. After 2 days the second week, I stopped taking the Med B pills, but the reaction continued with spikey fevers. I missed 3 days of work because of this reaction. It took another week for my body to return to normal.

So, I'd tried the Med B, the cheaper drug on the medical insurance formulary. My doctor submitted a new prior authorization request, describing my body's reaction to Med B. The pharmacy benefits manager denied that request, telling my doctor that I "had not taken Med B long enough." It would be another 3 months before I was able to return to taking Med A -- during that time I was dealing with the health condition also because I was not taking Med A -- because I changed medical insurance companies. The only reason the medical insurance company wanted me on Med B was because it was cheaper not that it might be a more effective treatment. In fact, as a result of the medical insurance company's actions and the pharmacy benefit manager's actions, they were essentially practicing medicine and prescribing a treatment for my health condition in order for them to save $150 a month. They totally destroyed continuity of care and they hurt me physically.

Money is no substitute for continuity of care whether that means keeping a medical provider or a medication. Medical insurance companies are walking a very thin line right now as they do everything they can to cut "losses" and increase their profits. The Affordable Care Act (Obamacare) is in trouble not because of the legislation itself but because insurance companies have worked in every way to undermine it. As I've said to friends, ignore medical insurance companies' advertising that claims they listen to their consumers and they're only thinking of the best way to save money and pay for effective treatment. They are not.  If they truly were, they would support and work to maintain continuity of care for consumers.

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