Health Care Plans to Kill You

In less than five paragraphs, Stay Free Magazine’s “How Hip Health Plan Breeds Superbugs” chillingly describes the nightmare plutopia in which we currently live—a world where not only are you chipperly reamed for twice the cost of your sinus medication, but are also softened up like veal for the slurping protuberances of a hyper-immune race of super bacteria.

No, the reason HIP covers less than a full supply is because it wants two co-payments out of me. At $30 each, that makes the drug $60. This not only makes the drug unduly expensive, but it encourages patients not to take their full course of antibiotics…. which, if you know anything about antibiotics, is dangerous from a public health perspective, because it can lead to drug-resistant bacteria.

Which, of course, is HIP’s entire insidious plot. A pallid, gel-like population of wheezing mouth breathers ridden through the streets by antibiotic junky bacteria jonesin’ for a fix. And who are these superbugs? As any reader who is familiar with the direct-to-video oeuvre of Brian Yuzna in the early 90’s will be quick to realize, these are the board of directors of HIP Healthcare itself.

One ancillary note: I have several hundred emails in my Spam Folder from friendly Zimbabweans who will all (with great politeness) attest that “Augmentin” does not, in fact, augment your tonsils.

Comments

Edit Your Comment

  1. HINKShopper says:

    “I recently buckled and talked to my doctor about getting some antibiotics. I asked for Augmentin . . .” Does the author ever mention what the doctor’s recommendation was?

    Sorry folks, speaking as a pharmacist, the primary culprit in antibiotic resistance has been over-use of these drugs in today’s consumer-centric marketplace. If the doctor in question had recommended sitting it out or easing up on the stress for a while, I’d wager it would have resulted in as much a rant about their insensitivity as we have about HIP’s policies.

    I’m not defending HIP here; their policy probably based less on wanting to milk the consumer and more on a system outlining dosing protocols by drug class (10 days is very common for antibiotics), in which case their pharmacy benefit manager needs to have a new one reamed for failing to adhere to proper dosing regimens.

  2. Michael A. B. says:

    I would say that HIP is doing the correct thing. They are not trying to get extra copays out of you. If you look at the manufacturers recomended prescription guidelines (at http://us.gsk.com/products/assets/us_augmentin_xr.pdf) you would see that the recomended course of treatment is 10 days of 2 tablets every 12 hours for Acute bacterial sinusitis (see chart on page 12). If anyone wants to sell more of a drug, it would be the drug company, but they say 10 days is plenty. The standard for good insurance companies is to follow the standards set by the AMA and the research that the drug companies supply. This appears to be what happened here.

    I will say that I work for an insurance company, but it is actually a competitor of HIP. I cannot say which one, unfortunately, due to corporate policies since I am not one of our public relations reps. I am sure that anyone who has ever worked for a corp of any kind understands this.
    Anyway, one of the biggest complaints that I get is that “You guys just deny coverage because you don’t want to pay for it. My doctor knows what treatment I need and I want what he prescribes.” Well, here are a few of facts on this.

    1) A large portion of our accounts are actually self funded. That means that we are paying the claims with the employers money, not ours. We have no actual incentive to NOT pay claims, for drugs or other services, other than the contractual agreement which our company has with the employer. If an employer REALLY wants us to pay something different that the contract, we require a detailed, signed agreement holding us harmless for the exception they are asking for and agreeing that they will make the same exception for any other identical situation.

    2) In cases where the payments ARE made out of our pocket, one thing that so many people don’t understand is this: Healthy people save insurance companies money! Getting a person healthy as quickly as possible is the best way to save money.

    3) The website that our company maintains has coverage positions which describe in explicit details what the criteria are for our company to cover a service under the “medically necessary” provisions. These coverage positions detail, in depth, every paper and study that we have used to establish those positions.

    4) Doctors are encouraged to review these positions, as are members when I talk to them, so that they are aware of the requirements when diagnosing and prescribing patients treatments.

    5) Provision is made to allow physicans to speak with our physicians and discuss, in depth, the treatment options avalible.

    6) While seeing a patient in person and examining them is always the best way to begin a diagnosis and treatment, if the treating physician ALWAYS knew best, we would not have the MASSIVE amount of malpractice suits in our country.

    7) Every decision that our company makes about approving or denying coverage for a member’s treatment is made by a physician. The mangers who handle the health services offices can tell the medical reviewers when to come in and when to go home, but they cannot even tell them to approve 1 less asprin than the guidelines suggest for the patient.

    Examples like the one above just go to show that even pharmacists and doctors don’t read the material put together by the company which spent years developing and testing the drug. Our company, for example, has a team of physicians who spend every day keeping up on the medical journals and AMA papers to ensure that we are not denying coverage for a treatment which is proven and effective for the presented disease.

    We do have to watch out for cost, obviously, so there are some cases where we cover the less expensive treatment before trying the more expensive one. These cases are situations where there are thousands of dollars of difference though.

    Xrays vs. MRI’s for example. An xray may cost $50-$200 and will give, in some cases, all the information which the doctor needs. An MRI extensive enough to give the same information can cost $1000-$3000 and may only reveal what the xray would reveal. You would not believe how many doctors that DON’T contract with health insurance companies send people right off for an MRI at the drop of a hat, even though that hat might be their hat on the sidewalk trying to collect money to pay for it. I have seen situations where a doctor calls for an authorization for an MRI without contrasting material. However, after our medical reviewers listen to the case, they have recomended that, given the situation, one with contrast and one without contrast will give the best imaging. This is, as you might imagine, more expensive, but it is one that happens from time to time. And before you think that I am tyring to say that it is altruistic of us, in a situation like this, the doctor would probably come right back needing the other service anyway and we would wind up paying both.

    All of this is from the point of view of someone that works at, what I think, is a very good company. The company which this lady mentioned, HIP, I did notice has class action suits against them for not paying some kind of anesthesia claims which they should have been paying. This is not good and I hope that the penalties they face represent the magnitude of the problem that they have caused their members, though I imagine it will not.

    I do what I do for one reason, someone needs me to do it. I used to work for this company and a international long distance company at the same time. I went to work one day, insurance customer service first, and spoke with a mother and father who had just joined our plan. They were calling because their 10 year old son had a degenerative disease which was going to kill him before 21. The doctors did not hold any hope for the child living much further than that. They were calling to get all of the details on doctors, hosptials, authorizations, covered drugs, emergency provisions, what to do if they were traveling, etc. They were doing this because they knew their son’s next emergency could be the last minutes they get to spend with him and they did not care to spend that time playing round robin 5 minutes before closing time trying to get something squared away. It was my honor to help these people, who I would say were facing this more bravely than any action hero I have ever seen.

    After that, I went to my other job and got yelled at for a charge of .43 on a phone bill for a call that the customer ADMITTED to making.

    That is when I decided where I was needed.

    Remember, if you are going to be a consumer, be an informed consumer. Don’t automatically blame the “nameless, faceless corporations” before you investigate. The guys at the top of the corps may be power hungry money grubbers, but the people paying your claims are just like you.

    Michael A. B.