Cost. Quality. Access. Guest Post by @Pharm_Thoughts


Thanks to @Pharm_Thoughts for this guest post about the US healthcare system. [I have wrote one on the NHS and prescription exemption which is for her blog readers in America]


I was once told these were the three problems every health care system in the world faced. You change one, the other two are affected. By and large, I have found this statement to be true. The one most people are focused on today, though, is cost.


We all know the cost of health care is rather hefty, regardless of whether it’s paid for by the government or by the patient. Between practitioner costs, diagnostic tests, blood tests, surgery, and medications, the costs can increase at an astronomical rate if a patient has a multitude of problems. This list is nowhere near all inclusive, as the term “health care” encompasses so much. Medications alone can get very expensive. I couldn’t even imagine having to pay out of pocket for everything. The one thing that’s really intriguing about it all, though, is the difference in the way health care is paid for in different countries. I’m going to review the health care system of the United States, focusing mainly on the retail pharmacy end of it, since that’s my area of expertise. To be even more specific, I am going to focus on private insurance companies, not government run programs, like our welfare programs or the insurance for our federal employees.


The United States does not have socialized health care. That is currently a huge political debate going on over here. There’s always some “hot button” topic going on during presidential election years, and that’s one of the topics of choice this time around. But, anyway, in the US, health care is almost more of a privilege than a right. Unless you fall into the welfare bracket, you have to find your own way to purchase health insurance, whether it be through an employer or through a private insurance company. There is actually a rather large number of people over here who are uninsured (49.9 million people is the most recent statistic). The only upside to this system is that supposedly our access to care is much greater than it would be if health care was paid for by the government (ex. I can get in to see my primary care physician as soon as the next business day if needed, but if we had national health insurance I may need to wait a few weeks before an appointment slot is available). I once thought this trade off wasn’t too bad, but that was before the economic recession hit here. Now, I’m not so sure.


Even though I have worked in a pharmacy setting for a huge chunk of my life now, I still find the insurance aspect of it mind boggling and frustrating. Pharmacy staff members spend at least 33% of their time dealing with insurance based problems in most US pharmacies. Most of these problems are easy fixes, but it still eats up a lot of time that could be better spent actually helping patients. This doesn’t even go into the auditing portion of it all. As an intern, I once spent a few hours with auditors from a major insurance company who were conducting audits on random prescriptions filled at pharmacies across the country. I had to go through hard copy scripts that were dated as far back as five years prior to that date. Five years! What a waste of time. And for what? The pennies that they paid for some prednisone and amitriptyline? There weren’t even any super expensive medications in the chunk of prescriptions I pulled for them. But, I digress. The point of that rant was just to emphasize how much valuable time is wasted with insurance companies when it could be better spent elsewhere.


Pulling my focus back to the medication area of US health care, there is one thing that needs to be understood. Here in the States, medical coverage and prescription coverage are two different things. You need to make sure you are paying for both coverages. People can easily make the mistake of only electing medical coverage and then not having any of their prescriptions paid for. Some places of employment provide prescription coverage for no extra charge as long as you have chosen medical coverage.


Not everyone is that lucky, unfortunately. To sum this portion up, US citizens have prescription coverage as a separate entity from their medical coverage. Every private insurance company is different when it comes to how much they charge and what medications they cover. Sometimes, they determine which pharmacies you can fill prescriptions at (usually big retail chains like Walgreens and CVS), and other times, they require you get maintenance medications from a mail order pharmacy. This is a major reason for the closing of many independent “Mom N’ Pop” pharmacies that have been around for half a century or more. As a general rule, medications fall into predetermined brackets or tiers. The bracket or tier the medication falls into determines what the patient owes. I will use my own prescription plan as an example:


Tier 1 – medications available as a generic (hydrochlorothiazide, lisinopril, metformin) — These are the cheapest medications. For me, these would be 7.50USD for 30 days’ worth or 15USD for 90 days.


Tier 2 – brand/proprietary drugs that are preferred by the insurance company (Benicar, Januvia, Crestor) — Generally, these are brand/proprietary drugs that do not have a generic available yet, but are considered a first line choice. These are slightly more expensive, since there is always a huge push to have people get as many generic medications as possible to decrease cost. For me, the insurance company would pay 80% of the total cost for 30 days’ worth.


Tier 3 – brand/proprietary drugs that are non-preferred (Aciphex, Testim, Omnaris) — Usually, these are brand/proprietary drugs that either have a generic available or can be substituted with a generic medication in the same class of drugs. These medications are even more expensive. Many people unfamiliar with health care costs sometimes think the price they are seeing is the actual price of the medication, when in reality, it’s a copay. For me, the insurance would only pay 65% of the total cost for 30 days’ worth. Specialty Tier – These include biologic agents, such as Humira, Enbrel, and Norvir. For me, they would cost 75USD for a 30 day supply. Non-covered – Generally speaking, these medications tend to be cosmetic or not medically necessary. The patient will be required to pay the full cost of the drug if they wish to use it. Latisse and Vaniqa are two big ones that almost every insurance provider does not cover. Also, weight loss drugs like phentermine fall into this category a lot. I would have to say that I am very lucky with my coverage. There are some people who pay much, much more for medications. I had a man with cancer come in the other day and refuse to take home his enoxaparin syringes because they would have cost him over 3,000USD. I urged the patient to get in contact with a patient advocate or prescription assistance program because of how important the medication is to his health. It turns out his insurance company moved the medication to a higher tier, which required him to pay more.


This whole tier-based system gets very confusing for many people and is far from fair in a lot of cases. Medications can change tiers from one year to the next. The formulary list is voted on by the insurance company’s executive panel. Though the panel does include health care professionals, it also includes business minded people. There are many times, both as a technician and as a pharmacist, I have called the insurance company for clarification on the price of a medication and have been told the patient’s individual plan or the medication formulary has changed since the patient had it filled last. That’s about as basic as I can get trying to explain the mess that is United States prescription drug coverage.


As a whole, the US health care system could improve a lot. I wouldn’t call it completely broken, but it’s far from perfect. Very far. But, then again, is any health care system truly perfect, or are we all trying to find ways to improve? You tell me.


3 thoughts on “Cost. Quality. Access. Guest Post by @Pharm_Thoughts

  1. This explanation is a ‘nice’ way of putting it.

    Far closer to reality, when in the thick of it, is a feeling of paranoia that overwhelms the pharmacist on realizing it’s a big shell money game, an attempt to spread the costs all around in a helter-skelter fashion, so that it seem there’s truly no relationship between actual costs and benefits.

    Perhaps, the only one that might not be swept up under the influence is someone who has never seen a healthcare provider of any sort and lives self-sufficiently.

  2. I haven’t lived in the US as well as the UK, so I’m not an expert, but the system described above looks completely broken. Give me NHS Scotland any day over that. It might take me a couple of days to get a routine GP appointment but I’m willing to take that in exchange for never having to pay a penny for treatment or medication for my entire life (except for what I already pay in taxes) and never having to worry about affording treatment should my income stop. You never even have to pay for condoms here in Scotland as the NHS will supply you with your choice from a wide range. And of course it means I never have to worry about sorting out insurance problems as a pharmacist,

  3. After coming back to work in Scotland after nearly 7yrs in England I was amazed by how efficient NHS Scotland is. It’s wonderful to be able to access care records, be able to make an out of hours appt for a patient, write emergency ‘prescriptions’ for emergency supplies and best of all- not have to bother filing all the scripts for end of the month by doctor!

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