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.
David Edelberg, MD