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I’m currently working for a major retail pharmacy as a pharmacy technician. Which is pretty unforgiving as a career, but it gives me a flexible schedule while I finish my last two years of school and also gives me a perspective of the US healthcare industry.

So, yesterday (a Saturday) a gentleman in his 80’s comes in to pick up 5 prescriptions for his wife who just had knee-replacement surgery. Four of them have been filled and the fifth, Oxycontin, for his wife’s pain, has been held up by the insurance and has not been filled. The insurance company demands, as it does very often, a prior authorization from the doctor. A prior authorization is basically a mechanism that insurance companies use to minimize their own costs related to patients’ coverage. It is paperwork a doctor fills out saying that, yes, my patient really does need this medication that I’m prescribing (as if the prescription itself wasn’t a good enough indication of that).

There are generally 3 ways things can go if the doctor submits the prior authorization paperwork. The insurance company may just flatly reject that the patient needs the medication, it can grant the doctors request that the patient receive the medication, or it can try to offer alternative medications that have similar effects (and are cheaper). Often, patients have already tried the alternative medications without success and this is usually a very tense and frustrating situation.

May I step back for a second and ask a question? What would happen, do you think, if the Affordable Care Act had included a single-payer system which introduced provisions that required doctors to fill out prior authorizations like insurance companies have been requiring doctors to do for decades?

Of course, conservatives would scream bloody murder, saying (correctly, in fact) that the government is getting “between a patient and his doctor”, that this is another step down the road to serfdom, etc. And I would think progressives and liberals would agree with them. If a doctor prescribes a medication for his patient, the patient should probably take the medicine.

So, this elderly gentleman spent 30 minutes at the pharmacy window trying to understand the situation before him, with a wife alone at home in pain. It was a Saturday, he would have to wait until Monday to get in touch with a doctor who was not his wife’s primary care doctor. He was, after all, the surgeon, and good luck getting in touch with him. Meanwhile, the wife does what? Deals with having a knee that just been removed and replaced with metal hinges without pain medication.

It’s just such a great example of how we do need the government to regulate the insurance industry, something which the Affordable Care Act does, to the extent it wasn’t watered down to appease moderate Republican votes.

After giving the elderly gentleman all the best advice I knew to give, he says “Well, I hope this helps us next time because she’s having the other knee replaced in a few months.”


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