I recently had a discussion with an angry patient. At the center of the interaction was the allowable day supply of one of his diabetic medications. The patient was questioning why I was only able to give them 7 vials of insulin instead of the 8 vials they wanted. To me, the answer is simple: 8 vials exceeds the allowable day supply as defined by their insurance benefit.
The patient asked me if I was taking care of him or his insurance. That is a fair question. I would always claim that I am a patient care provider first and pharmacy manager second. But limiting his medication supply based on arbitrary insurance rules does seem to contradict that assertion, given that his request was far from unreasonable.
The current healthcare system is a lot more complicated than the patient would admit. The insurance is paying for large parts of his medications, so they are entitled to have input as to the quantities they are willing to fund. And by that same argument, the patient has paid the insurance premiums for decades without utilizing the benefit significantly until now: why is the insurance unwilling to allow him a little flexibility now that he needs the care he has purchased? Complicate this with by considering that a motivated diabetic patient actively managing their disease and having adequate supplies of medication could save the insurance on claims over time, reducing healthcare expenditures and even patient premiums. This only begins to scratch the surface of the complexity!
Those of us working in health care, and being served by health care systems, are subject to an imperfect and complex system. It is important to keep an open mind and listen. This goes for both providers and patients.
During our discussion it became evident that the patient did not completely understanding the concept of day supply. He was under the assumption that the 7 vials would have to last him 90 days. I explained to him that in fact we were submitting the actual day supply the 7 vials would last. He would be able to refill the insulin as that day approached–before he would run out.
This was some consolation to the patient. Yes, they were being inconvenienced by having to come to the pharmacy more often than every 90 days, but he now understood that he would not be without his medication. The patient was still frustrated, and I believe that in his eyes I am still appeasing his insurance at his convenience and expense.
This is only one example of an underlying problem in healthcare: the lack of professional autonomy. Artificial constraints like day supply imposed on the provider completely ignore the needs and situations of the individual patient. Often they are a roadblock standing in the way of successful patient care.
If the provider does their job well, or the patient does not have any special concerns or issues, the patient is usually blissfully unaware of the complexity of the system in which they participate. Unfortunately, more and more patients are impacted by these system-imposed constraints. Our system has a long way to go to put the care back into healthcare. Our job is to do our best to care for our patients, Making Every Encounter Count.