Here’s something you don’t want to hear from your health insurer while suffering from an acute asthma attack. It seems that new HMSA procedures prevented a friend of mine from getting his medication for an acute asthma attack, at least until HMSA does its own second guessing. Since the incident took place at night, obviously that added review couldn’t be done immediately. Here’s what he had to say in an email overnight.
I went to Longs Manoa tonight to pick up my prescription for a drug to treat asthma, which I have an acute case of due to the vog. I have taken it before on prescription from my doctor.
Longs refused to give me the meds until my doctor talks to HMSA and gets clearance, otherwise HMSA won’t pay for it. It has nothing to do with me, I am assured, just a new policy from HMSA, which permits them to second guess my doctor regarding certain meds. They are now apparently practicing medicine.
It gives a whole new flavor to managed care doesn’t it?
It is a bit disquieting that a pharmacy, who has filled this prescription for me in the past without question, can withhold meds for an acute condition because HMSA says they need to make their own assessment.
I would guess that this is fallout from HMSA’s decision to outsource much of its operations to Healthways, a for-profit corporation traded on the NASDAQ. HMSA announced a new 10-year agreement back in January.
My friend’s situation could be an isolated case. It would be interesting to hear whether others report similar incidents.
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Interesting. That was not my experience when I went to my doc for asthma during the #$%^ing vog. She gave me a prescription for a new asthma inhaler and it was filled that afternoon at Longs.
The company I work for outsources its HR to Proservice. The HMSA plan they provide outsources the drug coverage to WHI – Walgreens Health Initiative. Luckily that does not mean the prescriptions have to be filled at Walgreen, which would be extremely inconvenient for me. What it DOES mean is this – WHI has a long list of drugs for which it requires pre-approval. The doctor is supposed to call a mainland number and get pre-approval before the prescription can be filled. This mainland number is only open Monday thru Friday during their normal business hours.
Very scary. I wish there was some way I could opt out of this. I may be forced to change jobs.
HMSA does not work with Walgreens as a PBM or Pharmacy Benefit Manager, it works with MEDCO. It may be that ProService only gets its medical plan thru HMSA and gets its drug plan from another company. Or maybe it has worked out a deal of its own with Walgreens to manage its drug benefit. In todays world it is more and more common that companies like ProService are working out deals of their own in an effort to find the lowest cost or improve their profits.
ProService is a very large PEO which means that is serves as the HR function for a large number of companies locally.
Managed care is corporate speak for managed torture and sometimes needless slow death. Your medical care decisions are no longer made by your doctor. They are made by corporate scoundrels. Luckily, in Hawaii there is an alternative to HMSA’s patient abuse. It’s called Kaiser.
I had a similar experience, at Manoa Longs, trying to get asmtha medication for my son, during the vog. We are on EUTF, and HMSA ousources its prescription drugs to InformedRx, a mainland mail order pharmacy benefits manager. Same end result – Longs could not fill the prescription because I had to go through InformedRx (which was news to me). I had to spend hours on the phone with InformedRx and have them mail it to me. Unbelievable, and incredibly dangerous. I seriously contemplated climbing over the counter and just taking the meds – my son needed it.
I filed a complaint with the SOH Insuance Division against against EUTF, HMSA and InformedRx. The Insurance Division rejected my complaint, practically by return mail, because it says it has no jurisdiction over self-funded (Taft Hartley) health plans. So our State does not believe it can regulate EUTF.
It is a reckless practice to put any of these delays between the prescribing physician and the pharmacist.
I thought InformedRX was for chronic conditions and ongoing prescriptions. Single or short-term prescriptions are supposed to be able to be filled locally. Or so I thought.
HMSA is NOT the carrier for the EUTF drug plan. InformedRX is and it is not via an outsource. That company was selected by the EUTF board to provide the drug plan to its members. You are blaming the wrong carrier. GO complain to the EUTF board and InformedRX. The EUTF did a poor job of educating its members when they switched carriers 3 years ago. Members were calling and complaining to HMSA which lost the business AND still helped all those people out because its was good community service. Your facts are incorrect.
As far as I know, the situation I wrote about did not involve the EUTF drug plan.
I do love my Kaiser insurance. Emailed my ortho with a question Sunday,he ordered an xray I can do at any Kaiser facility and he will do a phone consultation about the results-all for a $15 charge for the xray.
Although not directly related, if SB1274, now headed for conference committee, becomes law, those still allowed to appeal to the Insurance Commissioner will lose that right.
Those that will lose it include state legislators themselves. It’s a wonder that they would leave the healthcare of themselves and their families to the whims of HMSA. If the right of external appeal goes away, then we can count on insurance companies to increase their denials.
That bill also removes the definition of medical from statute and leaves it to the insurers. It’s unlikely, but possible, that the asthma drug could be declared not necessary for vog and that would be the last word on it.
Yet the bill moved all the way through to conference.
Ran into the same situation just before leaving for our current trip. The asthma prescription had to be routed to Informed Rx (EUTF contractor) by the doctor’s office. We received an automated telephone call saying they had to substitute another generic. Only trouble was my wife knows she’s allergic to the underling drug in the generic so we were out of luck and had to catch the plane and hope there is no flare up during our trip. No human to argue with but a robotic telephone voice substituting its judgement for her doctor’s.
Just got a bill for 700. for one month w my oxygen machine. It was 25. a month until now. My oxygen at night goes to dangerous lows, so doc prescribed this machine. I went and took the sleep test and they confirmed.
I guess I have to give it back now.
Some 3rd world countries have better health care than we do.
Ian,
Thanks for bringing attention to this situation. First of all, we’d like to help your friend. Please let him know that he should contact Kristine Nishimura, who is a pharmacist and HMSA’s manager of clinical pharmacy services, at 948-5514.
There aren’t enough details contained in his email or your blog post to specifically address what happened in this case, but here’s a general response.
We haven’t changed our prescription drug or formulary policy since entering into our new arrangement with Healthways, and we haven’t made any recent changes to our policies on asthma medications.
Drug policies fall under the HMSA Pharmacy and Therapeutics Advisory committee, which is made up of local practicing physicians and pharmacists. The policies help ensure that our members get the best possible care in a cost effective-manner.
There are a number of different medications used to treat asthma. Some of them used to control symptoms over the long term and others are used as rescue inhalers in the event of extreme asthmatic episodes. There are no clearances or pre-certifications required for rescue inhalers, which patients may need to obtain quickly and with some urgency. There are certain criteria in place for asthma drugs used over the long term.
Again, with more specific information we’ll be better able to help your friend, so please have him contact us. Depending on the specific circumstance, we may be able to work directly with the individual’s pharmacy on options to prevent a repeat of what happened to him.
Best,
Elisa (Yadao)
Vice President
HMSA Community Affairs
I predict that Kristine’s phone is gonna be rather busy tomorrow.
If nothing else, it is clear that HMSA does not communicate well with its partners, and it does not communicate will with its subscribers. How very sad.
I want to go to the next EUTF meeting. It is on 18 May, BUT they say they don’t know what time it will be held. How can that be?? What room??
Actually that is not clear at all. What is clear is that Ian is resorting to speculation about the cause of something without adequate disclosure of the details or understanding of the new business relationship.
The funny thing about communication is that it is a two way street. Consumers also have to read what is sent to them. The same applies to doctors. You might be surprised to know that a majority of consumers admit they dont read the insurance materials sent to them by their plan. Instead they wait until there is an issue then call Customer Service and ask how their plan works or complain because they dont know. I know the materials can be challenging to read but sometimes you just have to make the effort to understand them before its an issue.
Its also true that doctors often dont read the materials sent to them….and they admit that too then also complain, or their staff does. In both cases that is mostly ignorance and laziness. We all have to take responsibility for our care, our health and our role in the system.
The unfortunate part is that we all need to be paying attention or else we get surprised! Most of the programs that have been instituted in the last few years are in an effort to control costs and improve the quality of care. Today care is provided in volume….that costs more but the government, starting with Medicare and in its Health Care Reform push, is pushing for the system to improve quality. That means there will be changes for everyone…consumers, doctors , plans, you name it. You are seeing it already and will see more.
BTW, I have worked in and around health care at different times over 30 years so I have heard both doctors and consumers talk about it first hand many times. Sadly, the issues now are not much different than they were in 1980 when I first got involved. However the threat they pose to our economy, lifestyle, and national position are for more real now than then.