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A Computer Has Been Programmed To Medicate You

This will be scary.

Sometime in the near future you may find yourself signing for an unexpected package. Opening it, you’ll see a prescription drug bottle with your name on it, your family doctor the prescribing physician. From the label, you’ll find you’ve received a three-month supply with three refills, meaning this prescription is good for a full year. To make it easy and convenient, you can refill by dialing an 800# and having your credit card ready.

You recognize the drug as one for high cholesterol. Thinking back to your last check-up you remember your numbers were a little elevated, but your doctor had said to just cool it on the elephant ears and corn dogs and get more exercise.

Or maybe the new medication in your surprise package is for borderline diabetes or mild high blood pressure, though you recall your doc calling it “white-coat hypertension” and saying she wouldn’t be treating it with meds. Maybe the package contains two kinds of drugs. Or three.

If you’re of a generation that tends to be totally uncritical of doctors and their decision making, you think maybe you didn’t get your cholesterol down low enough after all, and you swallow your first pill. (FYI, if you’re 40 and you live to a perfectly reasonable 85, this is the first of 14,600 cholesterol pills you’ll uncritically swallow for the rest of your life.)

Let’s say, however, you’re skeptical, perhaps a little reluctant to take anything that arrives in the mail without verifying the source first. So you call the doctor’s office…just to check. Her physician’s assistant (PA) or certified nurse practitioner (CNP) answers your call. Yes, indeed, your doctor did prescribe the medication, and we’re glad you called because we’ll need to do a blood test in a month to make sure it’s working.

“OK,” you think. “So I’ve joined the rest of America with my statin…no big deal.”

How you got that package is pretty astonishing
I recently received from Blue Cross/Blue Shield a thick, oversized envelope marked “Confidential Information.” The cover letter, co-signed by BC’s chief medical officer and its director of pharmacy, began by reminding me how they shared my concern about the well-being of my patients.

The letter went on to describe a new “comprehensive approach to drug therapy opportunities” called GuidedHealth, which I learned is a software program capable of gathering information about you, the patient, to see if you might benefit from medications that I might not have considered (the aforementioned “drug therapy opportunities” and oh so Orwellian).

There were 33 pages in the envelope, one patient per page, 33 “opportunities.” Armed with a fistful of these pages, I started opening some of your charts. On the first page, GuidedHealth recommended a new antidepressant, revealing that this patient had been taking an antidepressant for four years, but had not refilled her prescription for some time. The computer that generated this “opportunity” was unaware my patient had started taking the antidepressant during a grueling divorce and had since happily remarried.

On the second notification, I was cautioned that the patient had an “increased risk for cardiovascular event” because of high cholesterol. Checking her chart, I noted that this was altogether wrong as her cholesterol was and is perfectly fine. I won’t bore you with further details, but after the first dozen patient charts, finding no missed “drug therapy opportunities” whatsoever, I gave up on this tedious task and poured myself a drink. (Don’t worry, I was at home.)

Then I did some investigating
It took me a few minutes to figure out why an insurance company like BC/BS (and I assume all insurance companies are doing this) would want to spend more money distributing more prescription drugs. Everyone knows the industry battle cry is “Deny!” and not “Here, have more!”

Then I went online. Amazing what a few clicks can reveal.

GuidedHealth is a software program developed by Prime Therapeutics, LLC, the pharmacy benefit manager privately held by 13 Blue Cross plans. It’s the largest of its kind in the US and its board of directors, as you might guess, are the CEOs of each of the 13 BC/BS plans.

When you switch from Walgreens to Prime Therapeutics
Every time you respond positively to a letter from BC/BS suggesting you shift your prescriptions from Walgreens or CVS to Prime Therapeutics, it’s a stab in the heart of Walgreens/CVS stockholders.

The carrot that Prime Therapeutics offers you is a tasty one: three-month supplies with fewer co-pays, telephone refills, and mail delivery. You may not have known that BC/BS owned Prime Therapeutics, but no big deal. In the US healthcare system, somebody’s always there to make a buck.

BC/BS and Prime Therapeutics chest-thump their not-for-profit status ad nauseam. But really, we should view this status as a tax dodge, their tax-exempt designation underwritten by the likes of you and me. They’re definitely not a not-for-profit like SmileTrain or Doctors Without Borders, for instance.  Not surprising, some states are getting fed up with Blue Cross having all the pleasures of a multibillion dollar company while taxpayers support it. Blue Shield of California, the state’s third largest insurer, recently had its tax-exempt status revoked.

Here’s how the profit is generated
When you’re prescribed generic meds, the actual drug cost is zilch, with some frequently prescribed drugs costing as little as $20 per 1000 tablets. The real cost to health insurers for generics is the so-called filling fee, a flat fee charged by drugstores like Walgreens for every prescription filled.

Hence the insurer’s enthusiasm for 90-day supplies, leading you to inevitably fill fewer prescriptions per year and your insurer to pay fewer filling fees. Of course, if you’re getting your meds through Prime Therapeutics, the pharmacists are BC/BS employees anyway, so BC/BS is actually reimbursing itself.

I have no beef with any of this. 90-day supplies are convenient for doctors, and most of us have better things to do with our lives than wander the aisles of Walgreen’s every month waiting for our prescriptions.

Indirectly, even your doctor profits from “drug therapy opportunities”
By receiving a notification that begins “patient X may be at increased risk for…” and because this notification is now part of the patient’s medical records, your doctor is at potential legal risk if she fails to act. If, heaven forbid, you fell over dead from a heart attack even though your cholesterol was perfectly normal, with that document in your records and no evidence that the doc or her staff called you, scheduled an appointment to retest you, counseled you, and wrote the prescription (or not), your physician could be held liable in a malpractice suit.

Let’s face it, folks, in any of the many overcrowded primary care offices around the country these days your doctor can cover her legal behind by turning over all her GuidedHealth “drug therapy opportunities” to one of her assistants, who will simply phone in the prescription and jot on the GuidedHealth letter that the doctor acted on the (computer generated) recommendation.

But your doctor can also benefit financially by writing a prescription you may not need in the first place.

Under the new Affordable Care Act, her practice likely sits under the umbrella of an Accountable Care Organization (ACO). In this system, the doc is positioned to be financially rewarded or penalized via computer scrutiny of her electronic medical records. The insurance companies want to know the results—both successes and failures–when she treats certain health risks, including diabetes, high cholesterol, or high blood pressure.

By following GuidedHealth’s “drug therapy opportunities,” using meds to lower your cholesterol and/or blood pressure actually earns her a few dollars more or wards off the penalty of a few bucks less for failing to do so.

Finally, BC/BS benefits significantly too
Blue Cross benefits from its own GuidedHealth recommendations, beyond just the pharmacy profits. The health insurance industry is, to use a cliché from business magazines, a fiercely competitive, dog-eat-dog world. When, say, Humana loses a big account, like a Fortune 500 company or a municipality, you’re talking serious money. What a VP of Benefits from a big corporation wants is not just the best price for group premiums, but a proactive company that can show hard data about how it monitors and acts on its group’s cholesterol levels and blood pressures, and even how it generates lower rates of coronary bypass operations or hospitalizations for depression.

With the cost of the meds themselves next to nothing, and by spreading prescription drugs like peanut butter across the American landscape, everyone–doctor, health insurer/pharmacy, even the corporation that foots the health insurance premium–can benefit.

Well, almost everyone. As your muscles throb painfully from your statin and your mind blurs from the antidepressant, you clutch a parking meter and nearly faint due to your new super-low blood pressure. Maybe you’re the real loser.

Be well,
David Edelberg, MD


Leave a Comment

  1. Tina Hepworth says:

    Love your posts Dr E! V amusing… but really quite horrifying! BXBS just sent us cards for ‘Teledoc’. For $40 ( or less) we can now call a Dr.( of some description ),somewhere, anytime/ in any language/about anything ( as long as it’s ‘relatively uncomplicated’- so hopefully the patient and/or the Dr. can make that decision over the phone!), get a diagnosis and a RX called in, in a few mins! All they wanted to know, to register, was basic health stats like height ,weight, age, sex,major health issues, allergies etc. Interesting-I suppose they’re hoping to cut down on the number of claims processed-or the number of clients total-who knows!

  2. Lynn Licastro RN says:

    Dr. Edelberg, thank God for docs like you….I became a nurse in 1972 LPN and 1978 RN..CCRN. I am so disappointed w my young fellow nurses who know no healing..just the corporate brainwashing. Will try teaching BCLS to have income…the conveyor belt of pts I had in amb. Day surg. Was mind numbing. 85 in 6 hrs w only 3 nurses. Las Vegas is the pits of health care. Miss you and Illinois!!!! Lynn

  3. ERAM says:

    One more reason the ACA is bad news. Thanks for another enlightening article!

  4. Deb S says:

    Dr. Edelberg, I recall a novel authored by Ira Levin back in 1970 entitled “This Perfect Day”. Plot description on Wikipedia – The world is managed by a central computer called UniComp which has been programmed to keep every single human on the surface of the earth in check. People are continually drugged by means of monthly treatments (delivered via transdermal spray or jet injector) so that they will remain satisfied and cooperative “Family members”.”

    Who knew this would come to pass? We don’t know what’s in the vaccines we allow ourselves and our children to be injected with (H1N1 vaccine was initially rejected by most Americans when it came out so vaccine manufacturers simply put the excess into the next year’s flu vaccines but didn’t advertise that). With government proposing mandated (forced) vaccines, it’s one less decision we will be allowed to make for ourselves. Will this prescription drug system become mandated as well? Stay tuned.

  5. Linda says:

    Dr. Edelberg, thank you for sharing this knowledge. It’s always alarming to hear the underlying issues and deep pockets in the health care industry today. I recently watched the movie Bought which brought to light similar issues that people should be aware of. I highly recommend you share it with your patients. Thank you so much for sharing your voice and inner knowledge that lay folks would not know.

  6. Cecilia says:

    I buy all my meds cheap as can be at Costco. I never want meds delivered by mail. They sit in freezing Chgo temps all day, or in brutal heat all summer, till delivered by mailman. And less meds we are on, the better. My doc said her first day at med school (Harvard) professor wrote on board: MEDICINE IS POISON…..she rarely prescribes meds….smart woman. Thx for your good info as always.

  7. Cheryl Culen says:

    Quite frankly you are the best doctor out there. I was seen by my PCP and W/C doctor and was authorized to see you. I called your office and was told you do not take W/C. I am a dual boarded NP who frankly felt hopeless upon learning that. You care more about people than big drug companies. Please reconsider taking W/C cases that would benefit from your experience.

  8. Dr E says:

    Hi Deb S
    Yes, “This Perfect Day” is a great book(as were Levin’s “Rosemary’s Baby,” “The Stepford Wives” and “The Boys from Brazil.” All utterly “unputdownable.”
    Hi Linda
    Read last weeks Health Tip–all about “Bought”
    Hi Cecilia
    Honestly, I never considered the weather issue and you are correct. The package inserts of many drugs show the temperature range allowable and of course drugs weren’t designed to endure a forty below wind-chill factor. Too bad the mailman’s pouch is not warm and toasty like a kangaroo’s
    Dr E

  9. Elaine Frick says:

    I’m alarmed by so many people recommending medications who are not physicians. Why are pharmacists, as in Walgreens, qualified to advise on whether or not one should receive a vaccine?

    I was in the hospital overnight recently for observation, and was offered a flu shot and a pneumonia shot. Also twice offered a heperin shot, so I wouldn’t get a blood clot. Is that standard procedure now?

    And thanks to Cecelia for the tip about Costco.

  10. Excellent article! It’s great to know what goes on behind the scenes at doctor’s offices.

    I’m 61 and on disability for a chronic illness after a tick bite. My disability attorney had to help me find a doctor because no one would accept me as a patient because I wasn’t 65. At least that’s what they said. My primary care doctors told me there would no longer accept me as a patient because they take very few Medicare patients.

    My doctor said Medicare won’t pay for any blood work, except my thyroid test, and I haven’t had a blood test in four years. This is so very difficult for me to understand! Maybe I have to have a heart attack first before they’ll check my blood. Anyway, I feel I’m stuck with an incompetent doctor.

    Does my doctor make more money if she doesn’t give me any tests

  11. John Pearson says:

    Another illustration with the problems with for profit health care. The ACA did allow me to get insurance, for which I am thankful, and unfortunately it also did a lot of bad things, like making sure insurance companies can still profit off of people’s health.
    I love Whole Health because they would rather see me be healthy than be medicated forever.

  12. Dr E says:

    Hi Lori
    To the astonishment of patients, in certain insurance systems the doctors do make more money when they order no tests. In fact, they make the most money if their appointment books are utterly empty. In HMO systems, for example, doctors receive a certain amount of money per patient every month. If they spend nothing (no tests, no medications) they get to keep the unspent money for themselves. That said, these days most doctors are salaried employees of large health care systems, so the corporation itself, rather than the individual doctor, keeps the money. However, to reward the doctor for spending no money on this patients, the corporation will give the doctor a financial bonus at the end of every year–or a rap on the knuckles if he/she overspends–or a job loss if he/she really overspends on your health care. For those of you who have heard “Sorry, no..” when you ask the doctor for a specific test or a referral to a specific specialist, it’s because you doc will be financially penalized for giving you what you want

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