PHARMACIST STEVE

Many employees that work for large companies may or may not be aware that their health insurance is provided by their employer on a self-insured basis, this is referred to as a ERISA prgm. It is claimed that about 50% of large employers are self-insured.  The employee is presented with a “health insurance card” and or a “Prescription drug card”  What the employee may or may not understand is that the well recognized name on their health insurance card is NOT AN INSURANCE but acting as an administrator for the employee to pay the medical expenses that is incurred by the employees and their families.  The “insurance company” has no real financial liability… they could be working on an administrative fee of so many $$$/employee/family and/or some percent of what is paid out as a administrative fee.

The insurance company will generally win the business from the employer with some “dog and pony show” … promising to help the employer lower overall health expenditures for the company. What the employer may not realize that saving money will mean coercing employees to use their mail order pharmacy, step therapy where the pt has to fail on the least costly med before they can “try” the next high cost med and sometimes any improvement is where the next step in the therapy is allowed to be tried… any improvement in QOL … is sufficient.

Also,what many employees don’t understand that there is someone within the company that has the authority to call the insurance/PBM company and tell them to pay for any med or procedure, because it is the employer’s money that is being spent.

Hypothetical,  an employee’s spouse is a chronic pain pt.  The insurance/PBM approached the employer to implement a opiate dosage reduction program… help prevent addiction among employees and/or family members.  So the insurance/PBM implements the CDC opiate dosing guidelines and puts a max MME/day at 90 MME’s. One or more of the employees or their spouses are fast/ultra fast metabolizers and dealing with CRPS… meaning that they are going to need high single doses and very frequent dosing per 24 hrs to help maintain their QOL.  These pts have been stable on very high doses for several years or a couple of decades… and their dose is slowly – or very quickly – reduced  and the pt starts becoming chair/bed/house confined..

Using the chart belong the employee goes to the person that oversees ERISA program.  Need to point out to this insurance/pbm point person… the number of very possible compromising the existing comorbidity issues and/or creates new comorbidity issues… One example is that under/untreated pain… will cause the pt’s system to keep pumping out adrenaline … which will mean that the pt’s adrenal glands will eventually fail and the pt will end up with Addison’s disease.

Here is a post on how liver damage can be for a pt who is taking Tylenol/Acetaminophen  https://www.pharmaciststeve.com/liver-injury-from-acetaminophen-at-low-doses-linked-to-fasting-heavy-drinking/   I can hear the first comment … my spouse doesn’t drink… great… but what happens when the pt goes into a flair and ends up in bed or on the living room couch for a few days..  DOESN’T EAT MUCH – like FASTING ?… they continue to take their Tylenol/Acetaminophen and ends up with liver damage.

Point out to the insurance/pbm contact person… things like their spouse could end up hypertension, resulting in eye and/or kidney damage. Could suffer a hypertensive crisis and end up with a paralyzing stroke and/or death…

The pt being forced to take NSAID and/or Tylenol/Acetaminophen… 15,000 people die every year from gastro bleeds from use/abuse of NSAID

The pt could end up with increased anxiety and/or depression

All of these issues – except death – is going to cost the employer money… paying for increase medical/hospital expenses because the insurance/PBM got the employer to let them introduce a opiate reduction program to help to keep employees and their family members from becoming addicted to opiates.

The number of possible complicated health issues for the chronic pain pt that has their opiate therapy reduced/eliminated.

Give the insurance/pbm contact person this chart and let them assign a $$$ figure to each of the possible health complications for their spouse and/or how many other spouses of employees could be impact in a equal or similar manner…  I suspect that the potential costs to the employer is MUCH … MUCH greater that the cost of paying for rehab for anyone who might become addicted and seeks treatment.

There is very seldom a situation when a MIDDLEMAN comes into a process that can cut overall costs of a program. Middlemen have a cost overhead and a desire to show a profit. It is more likely that middlemen will increase overall costs of a process.

 

Filed under: General Problems