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My kid recently needed a script. We had to go through a specialty pharmacy that ships directly to home because it apparently wasn't carried in the pharmacies li

My kid recently needed a script. We had to go through a specialty pharmacy that ships directly to home because it apparently wasn't carried in the pharmacies like CVS. The script was over $400. Insurance denied the claim. They "applied a coupon" and the price magically became $35. In this one transaction there's multiple layers of corruption most likely starting with the prescribing doctor.

alphabettsy 5y ago
Some doctors are certainly corrupt, but usually they have no way of knowing how much a particular medication costs since many do not buy or handle medication beyond what they would stock in their office. Your post lacks information such as whether or not the specialty medicine would’ve been approved with the proper paperwork from the doctor, but what likely happened is that someone at the pharmacy put in the effort to find a manufacturer coupon for the medicine for you. Interestingly the pharmacy doing that is generally forbidden in agreements with the insurance companies. That’s corruption imo. The insurance PBMs forcing you to use their designated specialty pharmacies is part of the massive healthcare consolidation over the last couple of decades and it’s full of corruption as well.
- Consultant32452 5y ago
  Of course my post lacks information. It's not a persuasive essay, it's an internet post about an experience I had. Humans tend to prefer brevity over exactness, particularly on internet posts.
  - deleted 5y ago
    [deleted]
  - codewiz 5y ago
    I prefer brevity over irrelevant information, but mentioning the specific type of drug, the name of the insurance and the type of coupon being applied would be highly relevant in determining whether the story has merit. Leaving it deliberately unspecified triggers all my bullshit detectors.
    - Consultant32452 5y ago
      - zdragnar 5y ago
        You alledge "multiple layers of corruption" when the reality is that manufacturers of specialty medicines often offer steel discounts to patients whose insurance companies don't cover their cost. For example, I took Taltz injections; my insurer wouldn't cover them unless I first tried cheaper options with much more serious side effects. Even if they did cover it, the co-pay would have been cost prohibitive for me. The reason my doctor prescribed it is simple- the manufacturer had a program that let you get it for $25 a dose if your insurance didnt cover it, or would cover all but $5 of the co-pay if you did. To be blunt, there's no conspiracy or corruption here. You don't get to throw out wild allocations with no specifics.
        saghm 5y ago
        You didn't name the type of insurance despite the fact that you argued the parent comment not naming the type of insurance as evidence their story was "bullshit". I point this out not because I'm saying your story is bullshit, but to point out the unnecessarily high standard you put on them. If you don't even remember to do it merely minutes after calling someone else for it, how could you possibly require that standard on a complete stranger who _hasn't_ brought that up as a standard when starting their own discussion?
        PebblesRox 5y ago
        You're accusing zdragnar of hypocrisy but it was codewiz who called bullshit on the lack of insurance details.
        zdragnar 5y ago
        Type of insurance is irrelevant to getting the manufacturer discount. If you dont have any insurance at all, you still get it. The point is if you are going to claim that there is corruption, it needs to be backed up by something. Serious claims require serious evidence.
  - alphabettsy 5y ago
    It wasn’t intended as criticism. I thought it was clear I offered that bit because I was speculating based on the information given.
- ddingus 5y ago
  Many insurers have rosters of meds they approve. Kaiser is one, just for a specific example. Everyone in the system is encouraged to prescribe from that list, even to the point of making clear medical trade-offs to do so. This was all explained to me when we had to switch plans, ended up with Kaiser for a while, and needed to renew blood pressure meds for my wife. She was in good control, no side effects, on meds for a decade. Those were not on the list. Rather than prescribe off list, that doctor increased her risk to benefit Kaiser, not her. And this was even made clear at the time! (maddening) Just to be ultra clear, it was that doctors "opinion" the various meds were all equivalent. For a lot of reasons, none of which are medical, we went with it, and sure enough, she was not in good control, and had side effects. Went back, got the meds that worked prescribed, (which cost me visit co-pays and some non trivial time and effort to basically demand the medication needed and proven) and found ourselves in the same "coupon" scenario above. Base cost of the medication was quite expensive, and a "coupon" was found to bring it roughly in line with the "on list" meds tried earlier. Of course, that all had to be done at another, outside pharmacy, due to the Kaiser one not carrying what they consider special order meds. That isn't a super big deal, but the whole mess involves bulk buying to gain price advantages, and the real worry point is cost being primary, with medical being secondary. The whole thing caused me to very seriously question the strength of "medical opinion", given patient history, a routine request to simply continue proven treatment turned into a risk scenario for no reason other than the tangled mess of insurers, agreements, drug manufacturers, and the like all more focused on profit than they are patient health. In my case, the pharmacy was Walgreens and yes they signed me up for some plan or other, GoodRX or the like, handed me a card and said I needed to use it to get the much better price. Was on the order of a few hundred dollars being discounted to a few tens of dollars... Have had similar experiences at CVS, Bi-Mart, Safeway... Indie pharmacies, usually niche places that offer things like compounding, are particularly good at this sort of thing and it's one of the ways they attract and keep patients. I used a good one for years, until I moved. Miss those people. They would do that automatically for anyone struggling with med costs of any kind.
  - ThrustVectoring 5y ago
    > The whole thing caused me to very seriously question the strength of "medical opinion", given patient history, a routine request to simply continue proven treatment turned into a risk scenario for no reason other than the tangled mess of insurers, agreements, drug manufacturers, and the like all more focused on profit than they are patient health. The flip side of this is the "pharmaceutical representative" entire job description. Basically, your doctor has a wide range of words they use to describe how to treat you. Some of them wind up with the insurance company paying $15 for generic medication, while others wind up doing something like spending $400 on something under patent protection. Pharma's reps jobs are to talk to physicians and educate/convince them to use the expensive words instead of the cheap words out of force of habit. Anyhow, that's why HMOs and insurers have approved medication lists - to push back against doctors writing down a $400 word instead of a $15 because a pharma representative said that FooBar XR treats Baz syndrome and the doctor wrote that down instead of the generic BarFoo.
heavyset_go 5y ago
The scary truth is that the prescribing doctor probably prescribed what they thought would best treat their patient's condition, and access to that medication requires hundreds of dollars because the manufacturer can simply charge that much, so why not? Your insurer denied you, again, because they can, so why not? Manufacturers give coupons that bring down the cost of their medications by hundreds, even thousands of dollars, so they have something to point to when they're accused of profiteering and exploitation. Your life and the lives of your family members depend on this system not fucking any of you over for a buck, despite fucking you over for a buck every step of the way.
nradov 5y ago
Do you have any factual evidence of corruption by the prescribing doctor? It is illegal for pharmacies and drug companies to give kickbacks to doctors. While that might still happen occasionally I guarantee you it is very rare. The vast majority of doctors write prescriptions based on what they think is medically best for the patient. If you have concerns over costs you can always ask the doctor if there is a cheaper alternative treatment to try.
- ARandomerDude 5y ago
  The kickbacks are indirect of course. BigPharmaCo tells BigPharmacyChain their new wonderdrug is wonderful, expensive, and ought to be popular, and therefore well advertised in the store. Meanwhile, BigPharmaCo sends reps to hospitals and clinics to offer doctors extremely well catered business lunches and complimentary luxury vacations -- I mean "seminars" -- to encourage them to prescribe the correct medicine. It is understood but not stated that if the doctor does so, the lunches and seminars will continue, as will the flow of large quantities of drug "samples" and other medical supplies. This situation incentivizes price gouging and over prescribing. Insurance companies are thrilled with high prices because they reinforce the idea that medical insurance is critical infrastructure. Liberal politicians love taking credit for throwing money at the problem they helped codify into law, and conservative politicians love being able to decry out-of-control, cradle-to-grave socialism at every campaign stop. So yeah there are multiple layers of corruption there.
  - refurb 5y ago
    As someone in the industry I can assure you this doesn’t happen. Or at least if it does, it rare and illegal.
    - deleted 5y ago
      [deleted]
wahern 5y ago
Drug coupons are common in the United States. AFAIU, they're issued by the pharmaceutical companies, but as few people know about them (or how the pricing system is structured in general) it's often doctors and pharmacies that seem to help broker their distribution. The coupon system permits pharmaceuticals and friendly politicians to deflect criticism about drug pricing strategies by providing plausible deniability regarding costs to the uninsured and underinsured. I remember reading several years ago reports that drug companies were favoring coupon distribution to doctors according to how often doctors prescribed the issuer's name-brand drugs instead of generics. That is, a doctor who prescribed a designer expensive drug, Foo, more often might get more coupons for name-brand but boring drug, Bar, for distribution to the doctor's indigent patients. I don't remember, however, if or which reforms were enacted as a result. Also, I'm not sure if it was nearly as big of an issue as actual kick-backs in the form of vacations, etc, which (AFAIU) were made illegal years ago. The opacity and overall baroqueness of the coupon system is precisely why there's not much opportunity for doctors to personally benefit from the scheme, yet why it works well as a tool for pharmaceutical companies to maximize profits while staving off political reforms. See https://en.wikipedia.org/wiki/Drug_coupon https://en.wikipedia.org/wiki/Drug_coupon
- datavirtue 5y ago
  Drug companies also kick back to patients. My wife started $65k per year infusions and the drug company paid our entire deductible for us after the first treatment.
- jdavis703 5y ago
  I only watch TV when there’s a sports championship or presidential debate. Even on those rare occasions there’s ads for GoodRX.
- daniel-cussen 5y ago
  Over time coupons could become valuable unto themselves as collectibles. I've seen collections of old South American mining town currencies (the highest denominations, in excellent condition), very colorful, all kinds of designs.
- 5y ago
devwastaken 5y ago
You're assigning blame to whom you are seeing - the doctor - whom is a worker like anyone else following a system. The true decision makers are people you don't see, like the administrators of that clinic, the pharmaceutcal company, and the insurance company. All business people that count on you to blame the workers for problems created by the admins whom by the nature of costs are trying to assign blame around in a circle. Everything is a company, and companies value profit over people. These companies are so massive and complicated in their roles and processes you and I cannot easily figure out specific actionable blame onto the specific administrators and processes involved.
- dantheman 5y ago
  You can say that, but the doctors are extremely high paid and exert huge amounts of power.
  - relaxing 5y ago
    The corporations involved (pharmaceuticals, insurers, hospital systems) each make 1000x what a single doctor does.
  - devwastaken 5y ago
    If we want to assign blame by proxy - by virtue of being a citizen in the U.S. people are all paying for other humans to be murdered by the U.S. military. Do we blame the powers that make those decisions and enact against those or do we blame all 300 million Americans and treat them as murderers? Blame those who made the system. Doctors are forced to work 80 hour weeks for not as much pay as you're thinking. Clinical Doctors don't have the power to better their own conditions, how are do they have the huge power to reform the regulatory issue of medicine pricing?
- EamonnMR 5y ago
  The only people with enough power in the system to demand a change are doctors. They could, example, refuse to do procedures until the billing department gets its act together and gives patients a price up front. They could demand to know the price to fill a prescription before they write it. If doctors took collective action to resist the horror show that is medical billing it would change overnight.
ClumsyPilot 5y ago
"They "applied a coupon" and the price magically became $35" This makes NFTs and drug dealers look honest. Oh, wait, they kinfld of are drug dealers.

alphabettsy 5y ago

Some doctors are certainly corrupt, but usually they have no way of knowing how much a particular medication costs since many do not buy or handle medication beyond what they would stock in their office. Your post lacks information such as whether or not the specialty medicine would’ve been approved with the proper paperwork from the doctor, but what likely happened is that someone at the pharmacy put in the effort to find a manufacturer coupon for the medicine for you. Interestingly the pharmacy doing that is generally forbidden in agreements with the insurance companies. That’s corruption imo. The insurance PBMs forcing you to use their designated specialty pharmacies is part of the massive healthcare consolidation over the last couple of decades and it’s full of corruption as well.

Consultant32452 5y ago
Of course my post lacks information. It's not a persuasive essay, it's an internet post about an experience I had. Humans tend to prefer brevity over exactness, particularly on internet posts.
- deleted 5y ago
  [deleted]
- codewiz 5y ago
  I prefer brevity over irrelevant information, but mentioning the specific type of drug, the name of the insurance and the type of coupon being applied would be highly relevant in determining whether the story has merit. Leaving it deliberately unspecified triggers all my bullshit detectors.
  - Consultant32452 5y ago
    - zdragnar 5y ago
      You alledge "multiple layers of corruption" when the reality is that manufacturers of specialty medicines often offer steel discounts to patients whose insurance companies don't cover their cost. For example, I took Taltz injections; my insurer wouldn't cover them unless I first tried cheaper options with much more serious side effects. Even if they did cover it, the co-pay would have been cost prohibitive for me. The reason my doctor prescribed it is simple- the manufacturer had a program that let you get it for $25 a dose if your insurance didnt cover it, or would cover all but $5 of the co-pay if you did. To be blunt, there's no conspiracy or corruption here. You don't get to throw out wild allocations with no specifics.
      - saghm 5y ago
        You didn't name the type of insurance despite the fact that you argued the parent comment not naming the type of insurance as evidence their story was "bullshit". I point this out not because I'm saying your story is bullshit, but to point out the unnecessarily high standard you put on them. If you don't even remember to do it merely minutes after calling someone else for it, how could you possibly require that standard on a complete stranger who _hasn't_ brought that up as a standard when starting their own discussion?
        PebblesRox 5y ago
        You're accusing zdragnar of hypocrisy but it was codewiz who called bullshit on the lack of insurance details.
        zdragnar 5y ago
        Type of insurance is irrelevant to getting the manufacturer discount. If you dont have any insurance at all, you still get it. The point is if you are going to claim that there is corruption, it needs to be backed up by something. Serious claims require serious evidence.
- alphabettsy 5y ago
  It wasn’t intended as criticism. I thought it was clear I offered that bit because I was speculating based on the information given.
ddingus 5y ago
Many insurers have rosters of meds they approve. Kaiser is one, just for a specific example. Everyone in the system is encouraged to prescribe from that list, even to the point of making clear medical trade-offs to do so. This was all explained to me when we had to switch plans, ended up with Kaiser for a while, and needed to renew blood pressure meds for my wife. She was in good control, no side effects, on meds for a decade. Those were not on the list. Rather than prescribe off list, that doctor increased her risk to benefit Kaiser, not her. And this was even made clear at the time! (maddening) Just to be ultra clear, it was that doctors "opinion" the various meds were all equivalent. For a lot of reasons, none of which are medical, we went with it, and sure enough, she was not in good control, and had side effects. Went back, got the meds that worked prescribed, (which cost me visit co-pays and some non trivial time and effort to basically demand the medication needed and proven) and found ourselves in the same "coupon" scenario above. Base cost of the medication was quite expensive, and a "coupon" was found to bring it roughly in line with the "on list" meds tried earlier. Of course, that all had to be done at another, outside pharmacy, due to the Kaiser one not carrying what they consider special order meds. That isn't a super big deal, but the whole mess involves bulk buying to gain price advantages, and the real worry point is cost being primary, with medical being secondary. The whole thing caused me to very seriously question the strength of "medical opinion", given patient history, a routine request to simply continue proven treatment turned into a risk scenario for no reason other than the tangled mess of insurers, agreements, drug manufacturers, and the like all more focused on profit than they are patient health. In my case, the pharmacy was Walgreens and yes they signed me up for some plan or other, GoodRX or the like, handed me a card and said I needed to use it to get the much better price. Was on the order of a few hundred dollars being discounted to a few tens of dollars... Have had similar experiences at CVS, Bi-Mart, Safeway... Indie pharmacies, usually niche places that offer things like compounding, are particularly good at this sort of thing and it's one of the ways they attract and keep patients. I used a good one for years, until I moved. Miss those people. They would do that automatically for anyone struggling with med costs of any kind.
- ThrustVectoring 5y ago
  > The whole thing caused me to very seriously question the strength of "medical opinion", given patient history, a routine request to simply continue proven treatment turned into a risk scenario for no reason other than the tangled mess of insurers, agreements, drug manufacturers, and the like all more focused on profit than they are patient health. The flip side of this is the "pharmaceutical representative" entire job description. Basically, your doctor has a wide range of words they use to describe how to treat you. Some of them wind up with the insurance company paying $15 for generic medication, while others wind up doing something like spending $400 on something under patent protection. Pharma's reps jobs are to talk to physicians and educate/convince them to use the expensive words instead of the cheap words out of force of habit. Anyhow, that's why HMOs and insurers have approved medication lists - to push back against doctors writing down a $400 word instead of a $15 because a pharma representative said that FooBar XR treats Baz syndrome and the doctor wrote that down instead of the generic BarFoo.

heavyset_go 5y ago

The scary truth is that the prescribing doctor probably prescribed what they thought would best treat their patient's condition, and access to that medication requires hundreds of dollars because the manufacturer can simply charge that much, so why not? Your insurer denied you, again, because they can, so why not? Manufacturers give coupons that bring down the cost of their medications by hundreds, even thousands of dollars, so they have something to point to when they're accused of profiteering and exploitation. Your life and the lives of your family members depend on this system not fucking any of you over for a buck, despite fucking you over for a buck every step of the way.

nradov 5y ago

Do you have any factual evidence of corruption by the prescribing doctor? It is illegal for pharmacies and drug companies to give kickbacks to doctors. While that might still happen occasionally I guarantee you it is very rare. The vast majority of doctors write prescriptions based on what they think is medically best for the patient. If you have concerns over costs you can always ask the doctor if there is a cheaper alternative treatment to try.

ARandomerDude 5y ago
The kickbacks are indirect of course. BigPharmaCo tells BigPharmacyChain their new wonderdrug is wonderful, expensive, and ought to be popular, and therefore well advertised in the store. Meanwhile, BigPharmaCo sends reps to hospitals and clinics to offer doctors extremely well catered business lunches and complimentary luxury vacations -- I mean "seminars" -- to encourage them to prescribe the correct medicine. It is understood but not stated that if the doctor does so, the lunches and seminars will continue, as will the flow of large quantities of drug "samples" and other medical supplies. This situation incentivizes price gouging and over prescribing. Insurance companies are thrilled with high prices because they reinforce the idea that medical insurance is critical infrastructure. Liberal politicians love taking credit for throwing money at the problem they helped codify into law, and conservative politicians love being able to decry out-of-control, cradle-to-grave socialism at every campaign stop. So yeah there are multiple layers of corruption there.
- refurb 5y ago
  As someone in the industry I can assure you this doesn’t happen. Or at least if it does, it rare and illegal.
  - deleted 5y ago
    [deleted]

wahern 5y ago

Drug coupons are common in the United States. AFAIU, they're issued by the pharmaceutical companies, but as few people know about them (or how the pricing system is structured in general) it's often doctors and pharmacies that seem to help broker their distribution. The coupon system permits pharmaceuticals and friendly politicians to deflect criticism about drug pricing strategies by providing plausible deniability regarding costs to the uninsured and underinsured. I remember reading several years ago reports that drug companies were favoring coupon distribution to doctors according to how often doctors prescribed the issuer's name-brand drugs instead of generics. That is, a doctor who prescribed a designer expensive drug, Foo, more often might get more coupons for name-brand but boring drug, Bar, for distribution to the doctor's indigent patients. I don't remember, however, if or which reforms were enacted as a result. Also, I'm not sure if it was nearly as big of an issue as actual kick-backs in the form of vacations, etc, which (AFAIU) were made illegal years ago. The opacity and overall baroqueness of the coupon system is precisely why there's not much opportunity for doctors to personally benefit from the scheme, yet why it works well as a tool for pharmaceutical companies to maximize profits while staving off political reforms. See https://en.wikipedia.org/wiki/Drug_coupon https://en.wikipedia.org/wiki/Drug_coupon

datavirtue 5y ago
Drug companies also kick back to patients. My wife started $65k per year infusions and the drug company paid our entire deductible for us after the first treatment.
jdavis703 5y ago
I only watch TV when there’s a sports championship or presidential debate. Even on those rare occasions there’s ads for GoodRX.
daniel-cussen 5y ago
Over time coupons could become valuable unto themselves as collectibles. I've seen collections of old South American mining town currencies (the highest denominations, in excellent condition), very colorful, all kinds of designs.
5y ago

devwastaken 5y ago

You're assigning blame to whom you are seeing - the doctor - whom is a worker like anyone else following a system. The true decision makers are people you don't see, like the administrators of that clinic, the pharmaceutcal company, and the insurance company. All business people that count on you to blame the workers for problems created by the admins whom by the nature of costs are trying to assign blame around in a circle. Everything is a company, and companies value profit over people. These companies are so massive and complicated in their roles and processes you and I cannot easily figure out specific actionable blame onto the specific administrators and processes involved.

dantheman 5y ago
You can say that, but the doctors are extremely high paid and exert huge amounts of power.
- relaxing 5y ago
  The corporations involved (pharmaceuticals, insurers, hospital systems) each make 1000x what a single doctor does.
- devwastaken 5y ago
  If we want to assign blame by proxy - by virtue of being a citizen in the U.S. people are all paying for other humans to be murdered by the U.S. military. Do we blame the powers that make those decisions and enact against those or do we blame all 300 million Americans and treat them as murderers? Blame those who made the system. Doctors are forced to work 80 hour weeks for not as much pay as you're thinking. Clinical Doctors don't have the power to better their own conditions, how are do they have the huge power to reform the regulatory issue of medicine pricing?
EamonnMR 5y ago
The only people with enough power in the system to demand a change are doctors. They could, example, refuse to do procedures until the billing department gets its act together and gives patients a price up front. They could demand to know the price to fill a prescription before they write it. If doctors took collective action to resist the horror show that is medical billing it would change overnight.

ClumsyPilot 5y ago

"They "applied a coupon" and the price magically became $35" This makes NFTs and drug dealers look honest. Oh, wait, they kinfld of are drug dealers.