Friday, August 15, 2014

Why The Fucking Flexeril Isn't Covered Anymore.

More than a few of you have come across this situation by now I bet. In the midst of a chaotic, stressful workday you finally snag an easy one. Thirty flexeril. Yay. Two seconds and we'll have this one right out the.....

Then you see the insurance reject. Prior auth required. What. The. Fuck.

We've all come to expect this with the bullshit drugs of course. And the expensive meds  with cheap alternatives. I'm looking at you Lyrica. One of the missions of the insurance companies is to save money after all.

But Flexeril? Are you kidding me? The generic is cheap as dirt. So I repeat, what the fuck? "They must be doing this for no other reason than to get me to crack" you might be thinking. "They've decided they must make each and every prescription a herculean effort to get out the door. There is a war on my sanity. Because there can be no logical reason to slap a prior auth on a seven dollar med."

Oh but there is a reason my poor underinformed retail drone. Logical or not can be a matter for debate, but read on to find out  why that insurance company pain in your ass just got a little bigger.

I'm going to go out on a limb here and say that rejected Flexeril claim was for a Medicare Part D patient. I know this because while you, my poor pillcounter, are still stuck in that outdated world where insurance companies obsess about nothing but money 24/7, I have seen the future, that bright new paradigm where the health care powers that be now obsess about.......money. But in completely new and innovative ways. Where an obsession with the dollar can lead to scrutiny of the most absurdly inexpensive of insurance claims.

It works like this. Someone got the bright idea that Medicare should do more than just sit there and pay claims sent in by the health care professional types. That since he who pays the bills can make the rules, they should use their bill-paying influence to try and influence quality of care. It was decided that Medicare would start to rate its Part D plans like AAA rates roadside motels, with a one to five star system.

So far this sounds OK, right? After all, who could argue with an effort to improve medical outcomes?

Next step involves how to go about being able to show how a large, paper-pushing, figure obsessed bureaucracy is improving things for the oldsters. How do we do that? We can't really just go around saying, " 'Ol Doc Johnson over there at Blue Cross of Lower Damnation does a pretty good job, Five stars for them!!" now can we? We need things to measure, so as we can compare like to like. Outcomes this year versus outcomes last year, Blue Cross versus Humana. In short, we need a way to generate numbers we can use in place of that unreliable human subjectivity.

I'll stop here the throw in the olive in the martini. Those star ratings are worth big bucks to the insurance companies, as Medicare pays bonuses to the highest rated plans.  It's estimated that the difference between a 3 star and 5 star rating is worth about $200 million to the plan getting rated.

That's right, the principle of using metrics to judge performance that has been such an unqualified success in making chain drugstores efficient customer service utopias has now been expanded to the realm of clinical judgement. In this case, Flexeril, the muscle relaxant that been part of the standard treatment plan for all sorts of painful conditions for longer than I have been alive, has been classified by some bureaucrat as a "high risk" medication for the oldsters. And a plan that goes over a 3% threshold of "high risk" meds is ineligible for a 5-star rating, and all the megabucks that goes with it.

So yeah, good luck getting them to approve that claim.

Except chances are, if you have a brain in your head and no desire to torture yourself, you won't even try. You'll notice that even if you moved heaven and earth and got that claim approved, the five dollar copay that would result isn't all that much less than you would normally charge a person with no insurance at all. As a matter of fact,  you could just say hell with the insurance company, charge the person five bucks,  make just a little less on the prescription than you would have anyway, and save yourself a hell of a lot of hassle.

It's a win win. And if grandpa gets a case of brain fog after popping a pill or two and falls down the stairs, it still goes down as a win for the insurance, as they don't have a claim for the "high risk" med on file, and therefore won't get dinged.

Meet the new health care order my friends. Where everyone wins, except the drugstore who made a little less on a prescription than they normally would have. And Medicare, who just paid out a big bonus that had zero impact on quality of care. And grandpa, who just fell down a flight of stairs.

Which means no one really won except the insurance companies.

Which means the new health care order looks a lot like the old health care order.

But at least you know why that pain in your ass is a little bigger now.

You're welcome.

9 comments:

Anonymous said...

You are so right on about this one!

Anonymous said...

You're wrong on this one! wtf are they supposed to do when they have a quality initiative. I mean, I imagine we could sell Norco otc at a price that would have it flying out the door, but we don't. Seriously, I know Norco could be priced at $10 for 20 and without having to do any pesky checking or counseling, oh how sweet the profits would be (gross margins for the pharmacy exceeding 20% with no hassle). All those regulations.

Or what about the tramadol above where you are going to bother to mention the pill limit. If you are going to have a license to dispense "dangerous drugs" in California, then it should mean something (like maybe you should think twice about just selling grandpa his flexeril at 5 bucks).

Just a rant; just like yours, but have you ever considered that flexeril isn't even that great a medicine - just cheap (I bet Norco would score better head to head).

Anonymous said...

I think you are both right and wrong on this one! I think the elderly patient needs to be empowered by our knowledge of why a certain medication is considered high risk, so that they can make an informed decision about their healthcare. To just fill the prescription at a discount without informing them of the potential for the cascade of fall, broken hip, and impending death due to complications of that situation, we as pharmacists are doing our elderly patients an injustice. You are so right about the non-transparency of the star ratings in the fact that most patients are still going to choose to take the high risk meds and pay cash which will not reflect on the star ratings, but adverse effects will still occur. I try everyday to talk my elderly patients out of taking zolpidem or temazepam, with a 100% failure rate. Most of the time it doesn't matter what we tell them, they will still choose to take their dangerous drug cocktails and prescribers will continue to prescribe them. The star ratings are a joke in this sense, but I ask, why are we just now trying to measure outcomes, shouldn't our healthcare system have been concerned about this all along?

Anonymous said...

I don't think you're right or wrong on this one! Not because I have a valid stance to support it, but because it's the natural progression from the last three comments.

Corresponding with this topic, though is the supreme annoyance I get from every single Humana Med B vs. Med D determination claim, that says a prior authorization is required for any acute treatment medication in existence written for a dialysis patient. PA required for Amoxicillin? Not a big deal, one might say, amoxicillin is a 2 dollar drug. But Ms. "I DONT HAVE A COPAY I PAY ZERO DOLLARS FOR EVERYTHING" does not agree with that, and insists you get her dentist to complete the prior authorization required for the medication. Her dentist, as you would expect, laughs and hangs up the phone.

Kennyc said...

At what point do we as pharmacists stop filling the flexeril for the elderly patientregardless of who pays for it? The reason behind the pa required rejection strongarm tactics is because as a whole pharmacists are not stepping up and managing/ educating patients. Pharmacist want to be paid and treated like members of the healthcare team, but ever increasingly act like automatic dispensing machines.

What role do you play in your patients Heath? Are you a dispenser or a pharmacist? Don't blame the insurance companies for quality related alerts. Remember that healthcare costs are much more than the cost of the medication.

DrugMonkey, Master of Pharmacy said...

Dear APhA nerds,

You're good kids, you really are, and I know your heart's in the right place, but before you start trying to impress us with your *cough* "doctor" *cough cough* of pharmacy brainpower, perhaps you should spend some time in an actual drugstore that fills actual prescriptions. It's obvious from your words you haven't.

You want to influence prescribing behavior in order to promote quality. That's great. It really is. But here's the thing, and I can't emphasize this enough, YOU HAVE TO DO THAT SOMEWHERE ELSE OTHER THAN THE POINT OF SALE!! Because number one, pharmacies are chaos, spend some time in one and it'll take you about 5 seconds to figure that out. If you wanna take a crack at calling Dr. Dumbass to initiate a prior auth while your other 4 phone lines are ringing, and grandpa's at the counter asking what's taking so long, and grandma wants her shingles vaccine, and great grandpa wants his purple pills refilled and crackhead is having a fit because you won't give him him his early norco and crackhead's girlfriend just called in a fake rx and your technician's trying to figure out the insurance card from Blue Cross of Buttfuckistan that actually gets billed to Express Scripts, go ahead, be my guest.

You probably have a better idea though, you're gonna break out those counselling chops from pharmacy practice lab and go over there and talk to grandpa yourself.

Bully for you. I'll direct your attention though, to the words "100 percent failure rate" in the comments above. And it doesn't take a *cough* "doctor" to understand why that is.

Because Einstein, when you go over there and tell grandpa that maybe the Flexeril might not be the best thing for his spasy muscles, you are now offering him a choice between what some dude who gives out dog food coupons with every flu shot says might not be optimal, and........nothing. Do you really think someone is going to walk away from the counter with nothing? Seriously? If they could make do with noting they wouldn't have gone to the (real) doctor in the first place.

"So, Mr. Smith. There's a bunch of eggheads that say this med might make you too drowsy, I mean, you might be likely to go home and sleep off this day that you feel like crap. We can't have that, so I'm going to call your doctor, and maybe in 2 or 3 days they'll get back to me with an answer when you're already starting to feel a little better" You'd have to be.....pretty dumb to take that deal. Yes?

So some free advice, "doctor." Get your head out of your textbook and think about how things work in the real world for a minute or two. Realize that medicine is not a cookbook, that guidelines are not laws. If they were, we could just do away with doctors and their pesky professional judgement altogether and practice medicine with algorithms. Despite your guidelines, there will be cases in which a course of Flexeril will do quite nicely where other (preferred by the textbook) meds fail. That's how things work in the real world. That's why we have (real) doctors whose job it it to examine people, not pages, and make a judgement.

So if you want to start an educational initiative on why Flexeril is over used, knock yourself out. Write up a CE, do an in-service, come up with an app that ties in with electronic medical records that makes sure prescribers have all the relevant information they need about their choices. But don't try to influence prescribing behavior at the point of sale. Anyone who's actually filled a prescription knows why.

red_No_4 said...

The post is what I have been thinking all along in regards to these new PAs.

Your response, DM, to the comments, is all that and more.

I still find it hysterical that no one gives a crap until you hit that magical age of 65. Then, it's all about Beers criteria this and 'what if someone falls' that. Did your pharmacy get the fax from Humana two years ago about medications they would no longer cover for the 'elderly' because they were on the Beers List? Fricking cowards, but at least it was a nice heads up. Were you as shocked as I was when the MedDs starting covering benzos? Enough cranky old people who can't sleep can bring a PBM to its knees faster than any pharmacist group.

Chances are if you've been on Flexeril for umpteen bajillion years, you're good. Turning 65 is not going to make it a bad thing. Just speaking from experience, as I have had several patients turn that magical number and now cannot get a medication that has helped them in the past unless they cash or have a discount card.

Lucky13 said...

I have another theory about these kinds of insurance rejects that require PAs for excessively cheap drugs: since they occur with drugs that are both cheap AND popular (zolpidem, cyclobenzaprine, fluticasone nasal spray), the insurance company saves $$$$ over a broad margin (the old, "take 2 cents out of every bank account in America and you'll be a billionaire!" kind of trick).

You also might notice that it occurs with cheap generics that still have ridiculously high AWPs (like ondansetron), as if the insurance company can't figure out a MAC based on real drug costs like they do for everything else.

But then that would compel everyone to realize that drug prices are based on fiction...shhh!!!

RxSeRPh said...

Holy shit . . . Med D covers benzos now? I have been away from retail for longer than I thought!

Also, dead on about counseling at the point of sale. Good luck with that, guys. It's the same reason MD's hand out Zpak's like M&Ms. Bronchitis? Zpak. Nevermind it's viral. Nevermind we are increasing resistance. Patient's need to feel like they got something for their time & money at the MD's office.

Just you try to talk them out of that. You lose a lot of credibility when you are dispensing medical advice across from the 'As Seen on TV!' endcap.