Part 3: Doing the Medicine Dance
I’ve lost track of the pleasant exchanges I’ve had recently with total strangers, all of us on Medicine Road wishing we were any place but here. Misery may love company, but empathy is one of the best human qualities. We all seem to show much more compassion and concern for each other standing in line at Walgreens or CVS than what’s so unfortunately common today in modern traffic. Nobody cuts the drug line or exchanges one-finger salutes. Instead, we smile and nod knowingly at each other and frequently discuss everything from the Spurs to Texas weather just to pass the time that so very often crawls by interminably when dealing with the consequences of illness.
A sign six feet or so from the counter directs our group to stand behind it. I’m told it’s to allow privacy for medicinal conversations, but the distance does little to impair hearing; I can almost always pick up word by word exchanges between staff and customers, and even many feet further away where a pharmacist now informs some agitated person over the phone she can’t fill a prescription because it’s held up for “prior authorization.”
“Sir, you can’t use four letter words,” the pharmacist says in exasperation and the admonishment apparently calms the caller enough so that she can explain why his prescription, and I’m sure many thousands more every day, are stuck in pharmaceutical purgatory.
“Prior authorization” is one of many new terms in my still expanding caretaker and insurance vocabulary and often prompts obscenities from me too, but I’m at least civil enough not to direct them at some unfortunate pharmacist forced into delivering bad news and instead save the vulgar rant for my windshield on the way home. In my mind, “prior authorization” is an obscenity itself, part of the spasmodic Medicine Dance required by insurance voodoo today.
Through much bad experience and observation on Medicine Road I’ve formed a mental picture of some dark and distant corporate office where two guys wearing bone necklaces toss stones across the floor as they chant “good medicine, bad medicine, oh all mighty Cost Controller reveal to us your wishes.” After the ritual, some pleas are granted, others cast into the fires of drugs denied, and then some poor employee at the corner drug store gets blasted, the truly guilty fully insulated by a labyrinth of different phone extensions, computer answering machines and distant offices where the real crimes take place.
Most seriously now, the insurance industry routinely blocks prescriptions and then requires a game of telephone tag on the part of doctors and pharmacists who simply don’t have the time to play games, something I’m sure the insurance industry understands well and employs to its benefit. I learned this in numerous ways, one from a very weary oncology nurse who called me well after her normal shift hours to explain she wasn’t able to break through the insurances company logjam.
“They kept transferring me from one department to another and then just put me on hold every time,” she explained.
In this case the blockade was over a controlled substance, hydrocodone with acetaminophen, prescribed after another drug, morphine sulfate, caused an allergic reaction that the nurse suspected was more likely caused by the solution the drug was suspended in than the drug itself. Hydrocodone pills were then substituted via another prescription that required a 40 mile round trip to obtain as doctors can no longer phone in controlled substance prescriptions, just anther part of the twenty step medicine jig.
The nurse and I both theorized the block was due to the second script being so close to the first one, actually a logical reason for questioning it, but the final result is one I’m sure insurance companies love the most: they didn’t have to pay on a legitimate claim.
“Can I just use cash for the new prescription?” I asked the most apologetic and very weary nurse, and she said I could, and then that’s just what I did. Most fortunately, hydrocodone pills are relatively inexpensive, about 70 cents each, so I just forked over 90 bucks and again cursed my windshield.
But it wasn’t a controlled substance that first introduced the term prior authorization. I learned that insurance curse chasing down sumatriptan, the generic equivalent for Imitrex, a drug used for severe migraines. We still don’t know what caused my wife’s migraines, both cancer and nerve damage resulting from her surgery are possibilities we’re told. Mary was also previously prone to occasional migraine attacks, but never as extreme as her most recent ones that were three steps past excruciating. She didn’t use words to convey this. I’ve heard this poor woman makes sounds I hope I’ll never hear again and came very close to recording them for evidence of mistreatment. The only reason I didn’t was that I couldn’t bear to hear her agony again, but still wanted to send a sound file to the insurance company with a bomb set go off just as the recording stopped, or so I imagined.
According to the insurance industry, in this case the explanation from CVS/Caremark’s website, prior authorization exists “to ensure safe, effective and appropriate use of selected drugs. Prior Authorization can ensure proper patient selection, dosage, drug administration and duration of selected drugs.” I guess in many circumstances this might actually be true, but in direct experience prior authorization exists mainly for one reason: to control costs, and in the case of sumatriptan, I really can’t fault the insurance industry.
Big Pharma has its hooks set deep in all of us and I have no idea who is mostly responsible for the price gouging or where the enormous profits flow. I only know that I was able to find an alternative source for the same drug that was enormously less expensive and equally effective, leading me to conclude something’s very wrong with the prescription drug industry.
With my wife literally howling from excruciating pain after her surgery that narcotics had little or no impact on, I was most fortunate to learn that my son had a reserve supply of sumatriptan as he also suffers periodic migraines. His prescription was for 50 mgs; my wife’s for 25 “every two hours as needed” so I could double my illegal supply while waiting for the prior authorization game to play out and the medical spigots to open, as they eventually did.
While I’ve grown to hate the insurance industry with a passion only exceeded for people like Hitler, my search and investigation of sumatriptan eventually led me to at least partially understand why insurers are often reluctant to fill some prescriptions.
As just explained, when I first encountered prior authorization it was in an attempt to fill a prescription for 25-milligram sumatriptan pills that retailed for about $20 a pill. Daily doses were limited to 200 mgs, meaning this single medication, now among many others required, could cost $160 every day. While this is very large money to a retired teacher and school secretary, it’s most important to note that many other critically essential drugs are far more expensive, quite commonly only to maximize profit. The most infamous example here is when now jailed “Pharma Bro” Martin Shkreli raised the cost of a cancer drug from $13.50 per tablet to $750.
As reason finally overtook deep fear of being unable to supply my wife’s prescription needs, I did a bit more investigation and discovered sumatriptan in 50 mg pills cost about the same at the local drugstore as the 25 mg pills, again not at all unusual in the legal drug world but still defying logic. I asked for refills in the larger dose and they were granted. I then cut the pills in half using a tool sold in most drug stores, as is the one I use to crush the pills into powder to get the medication through my wife’s feeding tube.
Then I found another sumatriptan door, one clearly revealing how terribly wrong current prices are for so many prescription drugs today. Pure and simple, it’s a racket folks, a most modern medicine show commonly inflicted on desperate people who have little or no choice but to spin the prescription wheel and hope for survival.
Trying to figure out why a generic drug was priced so expensively, I stumbled onto the on-line pharmacy business, in this case a Kentucky outfit doing business as Health Warehouse. Here I found 100 mg sumatriptan selling for $33.60 for 27 pills. Dividing the pills into quarter does of 25 mgs provided a 108-dose supply, lowering the cost to 31 cents per original prescribed dose, instead of about twenty bucks per pill for the first prescription I filled.
How was this possible? According to Health Warehouse, low overhead and not dealing with insurance companies help keep costs down.
“We aren’t burdened with substantial overhead costs of traditional retail pharmacy chains, nor the requirement to artificially keep prescription drug costs higher in order to maintain insurance reimbursements,” the company explains on its web site that also reports it is fully licensed to do business in all 50 states. The business also explained, “We are able to remove layers of cost between the manufacturer and the customer.” Just what kind and how many “layers” I’ve no idea, but did discover two things about the far less expensive replacement drug.
Upon receiving the prescription by mail I noticed, unlike the higher cost drug, the 100 mg tablets were not in individually sealed packets, now common to prevent tampering and also, according to industry information, to better preserve the drug.
For you youngsters out there, things like blister packaging for medicine became standard practice with a lot of over the counter drugs after some evil person poisoned complete strangers in the Chicago area in the 80s by opening Tylenol capsules, replacing the original drug with poison, and then placing the drugs back on the pharmacy shelf, random murders that were never solved but now mostly prevented by new packaging.
I also wondered if something like inferior quality might be involved with the new alternative sumatriptan, as is often the case with lots of products today, many manufactured in the third world and sold as substitutes for original, much better products. Having had both good and bad experiences with low cost alternatives, I initially feared I might be getting what I paid for, meaning not much. However, two things indicted otherwise.
I was initially concerned by the plainer packaging, a simple pill bottle with a black and white label indicating the drug was manufactured by Sun Pharmaceutical Industries in India. Having once bought a “new” motorcycle gas tank from India that leaked like a sieve and had more rust inside than the 50 year-old one I intended to replace, I began questioning my “bargain.” I then read the package on the much higher priced drug and learned that it came from the same company.
Knowing now both drugs had identical origin and distributed by a licensed US pharmacy, I felt much more comfortable about giving the far less expensive sumatriptan to my wife. She reported it worked just as well as the high dollar version.
While lots of prescriptions are difficult to fill today and often hugely over-priced, it can get even worse. You know things are really nuts when it’s easier and much cheaper to by heroin than it is to process a prescription for pain medication.
During one of my drug safaris I noticed a fellow unfortunate sitting in a chair provided for customers to wait for prescription processing. He held a bloody paper towel to his mouth and wore a pained expression that grew worse after he was called back to the counter.
“I’m sorry sir, we can’t fill this prescription,” the pharmacist informed the newest reject. “Your doctor didn’t include a DEA number.” The man nodded and left unmedicated, the paper towel still pressed against his mouth. He’d just hit another common pothole on Medicine Road, much tighter restrictions on controlled substances used to dull pain, the “Opiate Crisis” now in full frenzy, something I seriously doubt the man with the paper towel bandage had anything to do with but now suffered from the consequences, another innocent victim of a medical/social system in need of serious correction.