It’s been churning in my head for days. Again. It happens every time I move: the pharmacy-doctor-health insurance triangle got me trapped for just trying to cover basic needs.
This is nothing new for people living in the United States with a U.S. health insurance. It’s an unfortunate situation that haunts those who live here longer than just for an internship or for a study-abroad year during which most typically people carry along a health insurance from their home country.
If you live in the United States for real and are not super rich the health care disruption will get you, again and again. It’s daily (non-)news that the unsystematic system is broken. It’s frequent talk among colleagues and friends. It’s always good for a rant to share the latest absurdity. By the way, this has little to do with Obamacare; it was broken before and still is because of some fundamentally weird ways it has been set up. These are my two cents on the issue after having dealt with it from a patient perspective, or rather consumer perspective. After all, you have to remember it is all about the money, not the human.
So to my German or otherwise non-U.S. based readers, I want to offer a current sliver of experience with this strange arrangement. Alas, it differs so much from the German system (the only other health care system I have experienced) that it will be hard to explain all its kinks. Before getting to my most recent adventure in this bureaucratic jungle, here’s a quick primer on some fundamentals (flaws):
For starters, most typically you only have health insurance if you are employed, i.e. the employer picks your health insurance. If you’re out of a job, you are out of insurance. But while you are employed AND your spouse is employed you can also be double-insured.
Within the plans that your employer offers, you can choose between different alphabet soups of HMO, PPO, HSA, etc. I won’t even go there; it’s a mess to understand that is usually explained in a brochure as big and thick as a Spiegel magazine. A big dividing line runs between, most often, cheaper plans in which you are only allowed to visit pre-approved doctors in your state and those in which you can freely choose a doctor across the entire country (yeah, land of freedom!). You better think hard which one you pick because you’re only allowed to switch your plan once a year during a pre-defined, short period (unless you have a birth, death or wedding or other “life-changing event”). Otherwise you’re stuck.
Second, insurances do not necessarily cover all body parts. In my wallet, I currently carry 5, yes, 5 cards to “insure” the health of my entire body: 1 for my mind, 1 for my teeth, 1 for the rest of my body, 1 other one for the rest of my body (second insurance via J.), and 1 for prescriptions.
So you would think I am good to go. It’s in fact the best combination I have had so far in the country. Before, when I was only a student in Ohio, the university as my employer would not offer dental insurance. I shelled out about $100 each time I saw my dentist. When I was an intern, my employer did not offer me insurance but I had to look for an alumni insurance for recent graduates on my own.
Now with 5 jokers in my pocket, you would think it does the trick to be covered. But the thing is, you never know what is covered for how much until you visited your doctor. Which is the next thing that differs.
To find a doctor you first call the insurance to ask which doctor is covered. Then a robot-like human of the insurance tells you on the phone in legal language (after you work yourself through an automated message system and wait on hold for at least 15 minutes) that you still need to check with the doctor’s office if they work with your insurance. Then you call the doctor’s office and ask if they are working with your insurance. After they say yes, you cross your fingers that this is true, and you can finally make an appointment.
This still does not mean that everything routine you do is covered, e.g. yearly check ups on teeth, eyes or a standard physical. I had to pay over $100 for a routine eye check (which I hadn’t had for about two years). I had to pay over $400 with insurance to get my wisdom teeth removed. I had to pay over $100 for my routine dental check up. You get the idea… Almost every time you visit a doctor you pay a co-pay (Praxisgebühr) or a fee afterwards, or both. For each visit, at any doctor’s office, you either get a bill right away or an “explanation of benefits,” which tells me that my doctor’s office will send me a bill later.
I know Germans pay a lot each month in health insurance fees. While the monthly fee here might be sometimes lower, this is not always the case. Especially with Obamacare many people pay way more and get less and/or were forced to go to a new doctor (yes, call your insurance again to make sure the new one is covered.) My old dentist dumped me because of Obamacare and the university forced me to take on another insurance from their “wide” menu. Others pay thousands of dollars more for their family and still have to pay co-pays, fees and bills in addition.
So, now that we warmed up and considered these simple rules as the fertile ground for happy interactions with your insurance, doctor and pharmacy, we can dive into my current adventure.
Since I moved recently, I found myself a new doctor (remember lots of calling to figure this out). I had to ask the new doctor to write me a prescription for a routine medication I take regularly. Nothing extraordinary, something millions of people take all the time.
The doctor wrote the prescription. This does not mean that you get a neat little slip to take to the pharmacy of your choice. No, it means the doctor’s office calls in to a pharmacy that you need to pick in advance. Pharmacies here are usually at the back of any bigger supermarket. Imagine that inside your favorite supermarket, not far from the butcher’s counter, is another little counter or set of windows. That is where pharmacies are typically located. (Of course, also big drive-through pharmacies exist so you don’t have to leave your precious rolling metal cage.) Luckily, I already knew where I get my groceries most often. I gave the doctor the name of my supermarket.
I discussed with the doctor if I can keep using the brand I have been using. She said she did not know but that the pharmacy can tell me which generics I might be able to use instead. She said she cannot give me any medical advice on that. Brand v. generic plays a role again for what your insurance might cover or not. In my case it supposedly only covers the generic, not my brand. Hence my question to the doctor which effects a generic might have on my body. My doctor advises me to “shop around” at different pharmacies to get the brand I want.
In the supermarket pharmacy, I show them my shiny prescription insurance card. The assistant says the insurance covers the brand and the generic. Mmh, why did my insurance tell me they only cover the generic? Who is right? Happy that I can continue with my preferred brand, I learn I need to return to the supermarket the next day to pick up my brand.
The next day the pharmacy calls me, which is nice enough. But they tell me, oh no, they do not have my brand after all. Just the generic. I get the name of the generic. The pharmacist says it has the same active ingredient as the brand. I google it. Lots of horror stories pop up on different sites. Luckily, it just takes me three more phone calls to other supermarkets to “shop around” in the area. One supermarket tells me they don’t have a pharmacy albeit it says so on their website; the second also does not carry my brand, but the third does. After waiting on hold on the phone for another 10 minutes I get to talk to my new lucky chosen pharmacy. The assistant there cross-examines me quickly and starts a profile on me. Now my shiny new prescription joker gets activated; I give them all sorts of numbers they want to know. The pharmacy says they will send me a text message when my brand is delivered.
We’re not done yet. After finding the new lucky pharmacy, of course, I need to call my doctor’s office again to tell them to call in to this new pharmacy now with my prescription information. And by the way, also that the doctor needs to change the prescription so that I can pick up several packages at a time as my insurance allows. (Something my original pharmacy told me.) Otherwise, I have to go back to the pharmacy (which happens to be about the furthest distance as possible from my address in the same city) every so often just to pick up something I use all the time.
I just wait for 10 minutes on the phone of the doctor’s office to relay that I found a new lucky pharmacy. They say they will call in to this new one, adding the new information about several packages at a time.
Now I am only waiting for a text message from my new lucky pharmacy.
If I am super lucky my prescription insurance will cover the routine medication.
But who knows… I am yet to hold the right brand in my hand after working on the issue for just four meager days. And to see if a bill will follow.