As someone who used to work in office (I'm remote now and don't do anything with medications), the other inaccuracy here is the doctor never speaks to the pharmacy rep, he's too busy. One of the nurses does it (or worse, front desk) and there's a series of interactions between doctor and nurse before we get back to the pharmacist. That, or we do it all over fax and it takes up to 72 business hours for the doctor to approve a brand change.
As a non-American I must ask: messed up insurance system aside, if this is the case, why can't doctors just provide a list of all suitable options for a medication and pharmacy/patient/insurance company/whoever can pick whichever brand they prefer.
Here (Estonia) the doctors can write whatever brand they wish. The pharmacist is also legally obliged to offer alternatives with the same active ingredient.
@@Lightn0xdoctors deal with different insurance companies. Insurance companies will only cover certain treatments or drugs depending on the patients plan. It was as simple as you'd say, they'd do it. No one would want to do all this to and fro with the insurance company. It's v annoying and takes up a lot of time. I live in the UK. Don't get me wrong, the NHS isn't perfect but my auntie does live in the US and this is how she described it to me. So in the UK, doc sees patient and doesn't have to think about whether or not a patient can be given a test, meds etc. Just see and treat. In the US, my auntie first has to find out which docs she can go to from her insurance, then if any investigations or meds are needed, need to find out if it's covered by the insurance and even then, it'll all be based on certain circumstances. It's just long. Even ambulances cost. Where she lives, there's a 50/50 chance that if she calls an ambulance, the company the ambulance belongs to may not be covered by get insurance. There's no way of knowing. It's a mess. I thought paying would mean faster treatment and better health outcomes but that's not the case
I'm all for that. Now I'm waiting for the good doctor to explain to everyone why ophthalmologists get paid so much more for routine procedures (e.g. cataract surgery that can be performed almost assembly-line in outpatient centers) than than those done by surgeons in other specialties requiring just as many years of training. Going further, why are procedures of almost any type compensated so much more than similar time spent with patients?
@@ronaldmcyr156 Exactly what they want. Everyone whining about the other guy gets a little more here or there while they control the billions extracted for providing no care at all. We are being hit with mortars and this is like complaining that the other guy in the foxhole with you took the bigger apple in the chow line.
Sadly it means s nothing in the face of literal billions of dollars in lobbying & campaign contributions (aka bribes). The American people are (on average) too simple minded to accept a universal healthcare (or even insurance) solution because "communism". Obama didn't help any with his stupid remarks of "you can keep your doctor" when many could infact not keep their doctor thus poisoning the idea of universal health insurance even further.
It's not necessarily illegal. The company gives the insurance company a rebate. If the patient hasn't reached their deductable they have to pay full price and the insurance company pockets the rebate they received. There is no law that the insurance company has to pass on the rebate to the consumer, so this entire thing is legal
I worked retail pharmacy for about a year. I couldn't do it. It broke me mentally. My anxiety and depression couldn't handle always being the bad guy. I remember having to tell a desperate father that I couldnt dispense the medication for his sick child 3 days in a row because something kept getting rejected about the prescription every day. I just couldn't do it.
I always do my very best to be nice to pharmacists and techs for exactly this reason. Especially when they give me bad news. I know they have very little control over this bullshit system and there is no point in shooting the messenger. 😕
I have hit this never ending stream of new prior authorization needs for basic meds in the last couple months through my clinic. It is eating up about 5 hours per week which is all the "admin" time I'm allotted for extra charting. Our volume went from about 25/day to 45/day as of last week and we dropped down to one PA or NP covering that portion of our clinic. Haven't been able to play with my son at night for 2 weeks due to getting home right at bedtime. I hate how our healthcare is run. I just want to raise my family and help people.
I used to work in a pharmacy and this was an almost daily occurrence. It’s insane how long I’d spend on the phone with people who either said “we don’t cover it anymore” or “you need a prior authorization”.
@@BahamariaInsurance requires detailed paperwork from the doctor in order for the insurance to actually cover the med - basically insurance yelling "make me" and running away forcing the doctor to chase after the coverage
@@Bahamaria It is the second prescription your doctor has to send to the insurance after they didn't believe the doctor just sent the first prescription... AKA a great way to kick a bill just a little further down the road if not discourage patients from trying to be healthier all together
As a US pharmacist, the pain of this video is all too real. The only thing is he missed the "oh, now you have to pay a brand name copay for the drug that we won't cover as the generic". So now they have a $100 copay on brand name med that the generic costs $45 cash.
That's about to happen to one of my meds. The patent JUST expired like a month ago, and the brand name manufacturer started ramping down production even before the expiration. So now you can't find a pharmacy with either the brand name or generic in most doses. Had to call 30 different pharmacies to find one that had a close enough dose and got my doctor to lower my dose and send it to that particular pharmacy. (Not a "live or die" medication but an improved QOL med.) I know my insurance will cover name brand, but they haven't updated the formulary yet to cover generic. The brand name is over $400, but they also have a $60 coupon, so my copay usually ended up around $45. No clue yet how much the generic will be cash because no one can actually get it lmao. I've hit my OOP max for the year tho, so I'll take the brand name from now on just to force the insurance to update their formulary quicker, lol.
United health loves it if you decide to skip insurance for the lower cost generic. They still keep your monthly premium and don’t have to pay for your drug!
@@wolfoftheagesUnfortunately, from experience, the generic becoming available doesn't save you money immediately... It MIGHT be cheaper, but only just. It takes a few years before the costs settle into being actually reasonable.
@@wolfoftheages I know exactly what med you are talking about. 60 and 70mg are non-existent, one patient told me they called every pharmacy in the city and no one had any. Good thing is the backorder on the generic extended release for the OG drug in the class is finally starting to ease up and we've been able to get a few bottles here and there.
Can a customer just say ok I'll just buy the generic? An insurance company tried that on me and I was like ok out of pocket it is- it's cheaper for me anyway
Politicians: but we can't nationalise health care. The government is so inefficient. US: Spends far more on administrative costs related to healthcare than any other nation because of how hard it is to order medication.
@@strawdemindsetit would help if people stopped being brainwashed into the 2 party system. But I think there's a higher chance of 15 or more generations dying and\or the sun exploding before that happens
@@strawdemindset Oh, please, don't choose model our system, it's in the process of being eroded and ever more privatized to make it more like the USA's. Please choose one of the Nordic countries.
As someone starting medical school in the UK, I'm studying this series carefully so I can get a handle on the way prescribing will be over here in 10-15 years. Thanks for the course. How much do I owe you?
In fairness I don't think it would be as bad as this even if we completely shove the NHS out the window. Our laws tend to be more consumer protective so things like insulin prices would be more likely to remain ok. That said I'm also starting med school in the UK and I am also getting myself familiar with these things just in case lol
People have been saying the NHS will be replaced by a US style system since Clement Attlee lost in 1951 it hasn't happened because no one wants a US system. But you do know you have to pay in many EU countries right? especially for non emergency care. The simple fact is the number of workers per retirees (who need the most medical care) is going down so it's either more tax (which can be diverted by governments) or personnel insurance the best thing today is clearly set up a government started but not run by (like the BBC) insurance trust for those just entering the jobs market that will be used to fund long term care and medical expenses either dur to age or accident related issues. Normal A&E can be kept as free tax funded but any long term meds or care can come out of a persons personnel insurance. Raising taxes is a dead end as people don't want it hell look at anyone who works as a contractor when the government wants building work done they take 10 times as long and charge 10 times as much because they want to get their tax back ignoring that the tax is supposed to pay for running the country.
One of the greatest assets that the NHS has is being able to negotiate on drug prices. They even have a hard limit for the amount they'll pay for a certain amount of benefit. This means that pharma companies can't make runaway profits in the UK and *that* is what the Tories actually want to change. So increasing taxes or not actually doesn't have much to do with it.
because that's actually where we are a third rate banana republic. the quality of care for those who can afford it is not the issue with American health care.
if money isnt a factor, american healthcare is pretty good, so youd find it difficult to talk much about it in that regard its just that money is a factor for anyone who isnt a mulitmillionaire
Pharmacist here. I’ve just been triggered!!! 😱😱😱 The accuracy of this vid is astounding & horrifyingly true ~ except at how fast this can be done!! I’m so glad I’m retired now!! 😂😂😂
My favorite is after doing a prior authorization for a prescription, the insurance company turns around and says, “Just kidding, we really didn’t need that! We just hoped you’d give up and not make us spend any of the patient’s money.”
As frustrating as that unnecessary runaround is, at least in most of those cases the medication still gets covered. Sometimes you switch to the formulary approved drug, do the perplexing prior authorization that they STILL require even though you picked the formulary drug, and then even though it's covered, the co-pay is too expensive for the patient to afford anyway!
Great summary. A hidden cost here people don't see is we just wasted precious time of a pharmacist and pediatrician for non-direct patient care items. Another thing that increases healthcare costs.
[Screams of anguish] I take Qvar. My pulmonologist writes my prescription for two puffs twice a day instead of one so I hit the 90-day medication maximum for three inhalers instead of having to buy them one at a time for maximum price. (They can't give me two for the 90-day price because that would be 120 days of meds and you can't have more than 90. Never mind that I've been taking these meds for decades.)
I feel this in my BONES. Well... lungs. Asmanex is the only asthma control med that works for me. It works amazingly with zero side effects. I've tried *everything else*. Either horrible side effects, doesn't help, or actually makes asthma worse. My doctor and his staff have wasted so much goddamn time writing appeals for me... for a medication that's worked since 2006. Caremark eventually covered it kinda. But for some reason I can't get the full dose I need. When I'm having a flare up I'm supposed to take 220mcg twice a day. For some reason, I can only get 30 doses of 110mcg, or 14 doses of 220. Soooo a quarter of what I need. My doctor did some gymnastics and got me two 14 dose 220 twisthalers this last time. They took a few weeks to get in to my local CVS. I need them. But I'm too scared to use them now, bc I know I'll need them more critically if I have a virally induced uptick in asthma and it'll be really hard to get. Sooooo yeahhh... Oh, and my kid takes symbicort, and we both have epi pens. Just...yaknow..adding to the fun. It's like they'd rather people die from life threatening but easily treatable things than actually let us be treated by the meds our doctors know work for us. It feels like a eugenics loophole tbh.
@@WxBugginOhhh, you said the quiet part out loud!! No but seriously, some of the shit that's being pulled in the healthcare industry absolutely hurts the sickest people worst of all. The word "eugenics" has certainly crossed my mind as well.
You just made my month Doc! Almost enough to make me forget that I owe 2000 for a single X-ray after a babysitter thought my 1 year old swallowed a button battery and my insurance only covered 600 even though this happened in late September because our deductible was not met. Hopefully Jimothy can make a difference.
The most absurd part is when the insurance will only cover brand, but the brand *copay* is higher than the *self-pay* price for generic. Which in my experience as a pharmacist seems to be about half the time these kickback shenanigans are in play.
Shouldn't you just take the generic then? If the generic cost without insurance is lower than the brand name *with* insurance, why would you still take the brand name?
@@raznaakit's hard to know ahead of time. Only very very few pharmacists will bother to calculate _both_ prices and see which one is lower. Dunno if it's a software thing, time issue, apathy, or a bit of all of them. I've personally experienced this when a pharmacy called me to say that insurance wouldn't cover it for x, y, and z. I said, well, what's the price without insurance? It was something ridiculous like $5. I said, why are u even calling me?? Just fill it and tell me I get a good customer discount 😂
@@kap4020 huh. For all the medications I took (not much mind you, but still some), the pharmacist told me my options before I pay. Like, when my doctor prescribed me a brand name, the pharmacist told me I could pay X for it, but Y for the generic that works the same for what I needed. Granted, in Québec we have a public medication insurance that covers generics better than most brand names but still... How it works here: all non-medication healthcare costs are always covered by the public healthcare that is comprised within our taxes (except of course teeth, they're still luxury bones here too). Medication given to you in a clinic or hospital are also covered while you're there, but once you're out you pay for the prescribed medication. The public medication insurance is ~600$ per year included in your taxes declaration and covers like 20%-80% of the prices of medication depending on many factors (which are already peanuts compared to the USA but still not that cheap sometimes). You can choose to opt out of it and the 600$ of taxes, but you MUST prove you have a private insurance, no one is allowed to be uninsured. Private insurances work basically the same as other insurances, so minimum amount before they start to pay, they can refuse to pay depending on your plan, and many other problems... If you don't have a lot of medication to take, public insurance is sufficient, but if you're in a family that takes a LOT of medications, the private insurances can be worth it on the long run.
@@raznaak-- Precisely what the insurance company is hoping is going to happen. They don't care how much time and energy is wasted doing this song and dance before the patient ends up paying out-of-pocket. And as somebody else already mentioned, we have no idea what the patient's out-of-pocket cost is going to be until after we send the Rx, the pharmacy runs it through the system, and finds out how much it's going to set the pt back. Even for generics that have been out for decades and are made by 20 different companies. For example, about five or six years ago, the cash price for generic doxycycline -- a tetracycline derivative that has been FDA approved and on the market since **1967** -- was all of a sudden more expensive than newer antibiotics that were still brand-name only. There was some vague talk about a shortage of raw materials for manufacturing, but I never got a good enough explanation from anybody about why the price went through the roof. Doxy is back to being cheap again these days, but you just don't know what your patient is going to face at the cash register even when you write for a generic.
You have totally captured my insurance company, BUPA! I was hospitalized six months ago for two major surgeries and spent more time on the phone arguing with the company than I spent recovering. Oh, I almost forgot to mention, I spend $15,000 for international premium insurance and have too many preexisting conditions to change companies.
I'm a utilization review nurse for a hospital typing this while on hold with UHC trying to set up a peer to peer. Please do one on their phone tree and/or how they generate a million auth numbers for the same encounter. Placed in obs? One number. Updated to inpatient? Two more auth numbers. Denial? New auth number. Then when you call for a peer to peer, they're confused about which auth you mean. Edit: when I got them on the line, they did it again. Multiple auth numbers. I figured out their game and they forwarded me to a phone tree.
The phone trees I've had to deal with the last two or three weeks have almost made me lose my mind. I swear they're just getting longer and more obtuse. Just trying to reach the same person/department you were JUST talking to shouldn't have to take literal minutes. Maybe it's saving them time, but it's killing me.
@@safaiaryu12Most of the calls go to a call center. The people who answer the phone are all spread out throughout the USA. We can’t just transfer you to Jenny because we have no idea who Jenny is. Most call centers are not equipped to do anything. The reps work from home. It’s all micromanaging by superiors. Those of us who have a soul cry on a daily basis. It’s all about numbers not people who are suffering. When you are the patient and the call center rep it’s soul crushing. It’s even worse when you clock out to get on the your cell phone to call a call center for your immunosuppressant medication to get the round around. Some of these organizations are worth billions of dollars but the patient is not a priority. If one or two people sue or worse die they still have billions and are not bothered. Supervisor’s weed out the reps that care because we are on the phone trying to find someone within the organization with a pulse to help us help the patient. It’s so sad to hear another rep tell you that’s not their problem that a medication isn’t covered or that the patient has been on the phone for days. It’s a sad state of affairs in America.
As a nurse who helped patients with insulin, this is the TRUTH!!!!! So much time and energy that we don't have. I hope you do the "let me transfer and hand up on you 6 times" episode!
I can't imagine the ordeal of practising in the USA. Just the other day, I gave a pt in the ER a medication that costs over 6000EUR as easy as giving paracetamol... Be strong there! 💪
The dartboard is urban legend . Insurance companies use a very sophisticated computer algorithm that takes into account variability in the supply and demand ( and therefore , pricing of drugs ) of APIs for the Pharma industry . Just kidding , they have a " Chicken Bingo " app . The Pharma companies use dartboards to set pricing .
Sometimes I get awfully frustrated watching Dr. Glauc videos and then I remember I live nowhere near U.S. Have to actively remind myself "not my circus not my clowns" to calm down Hope this goes viral and things change for better
@lj-ho5wg The Junior Doctors' strike in UK for pay restoration that's been going on for months now, started from what was essentially a series of legendary shitposting on reddit. So maybe, Dr.Glauc could be "it" for the US.
We'd have to do an entire sweep-out of our current government for things to get better. They're not going to change anything so long as Big Pharma and the insurance industry are lining their pockets. The money speaks way louder than our votes.
I have to say as a UHC patient, this is accurate. My oncologist prescribed Zofran and they would only cover the sublingual tablets and she had to submit a prior authorization. When I went in the next time it was only the regular tablet and no orior authorization needed, but would only cover 4mg tablets, not the 8mg. And back to sublingual tablets the next time. Finally we got fed up, and she ordered the really expensive IV medications for home administration via my port, and they didn't blink an eye.
Also fun fact the only generic on the market for Flovent is manufactured by GSK the maker of the brand so they would get all of the money anyway but still incentivize insurance companies to have brand on their formulary because brand medication claims get reimbursed to pharmacies at different (usually worse) rates than generics! 🙃 And the copay is still usually asinine as well.
Ooh! Don't forget about the part where the insurance charged the pharmacy a fee for everytime they submitted the claim only for it to be rejected with an ambiguous denial code that required a phone call to clarify!
And the part where the insurance will only reimburse the pharmacy for part of the cost of the medication. Even including the copay we loose money on ~40% of our prescriptions....BEFORE you take into account the processing fees...or over head (bottle, label, tech, pharmacist, etc). Or the fact that they'll "say" we're going to make money on a prescription, only to come back 6 months - 10 years later and say "we over paid you so we're going to reclaim some of that money" but not tell you what claim it is for or what the random $5,000 "fee" is that we're being charged.
Or the part where the insurance owns their own pharmacy and makes getting maintenance meds at your local pharmacy so convoluted and consistently delayed, that in order to keep reliable access you have to use their pharmacy. It shouldn't even be legal for them to be pharmaceutical insurance and the pharmacy too.
Thank yooou this one is too real. I might start showing it to my patients when I prescribe them an inhaler so they know why it often takes a few days to get the “right” script figured out
Meanwhile in Australia I walk in the pharmacy with my script. Pharmacist tells me “your doctor has prescribed a brand name med that costs $40 do you want to switch to the generic and save $10?” No need to call anyone as they are same medication and pharmacist allowed to switch brands.
Meanwhile in Japan, the government negotiates on our behalf for reasonable prices, and since medications are more straightforward here with government health insurance...our pharmacists aren't dealing with approvals and have time to consult in a meaningful way with patients about what we're taking. (No HMOs either - we choose our own doctors and pharmacists freely because nearly everyone participates in the government system.) Like all healthcare systems, there are real problems here too, but hassle free access to needed medication Japan does extremely well, and I wish it could be copied in America. You all deserve so much better than what you have.
Ditto on the lobbyist and stock ownership angles that are keeping our politicians from doing a damn thing about this. We need reform in Congress, and in the Fed executive branch, and Fed judicial branch, requiring everybody to divest from all individual stocks before taking office and switching everything into an index fund. Same for their immediate families, including adult children, elderly parents, siblings, etc. And we also need to kick 75% of the bums out and replace them with people who will pledge not to take money from lobbyists.
@@Louis_Marcotteyes but then the scumbags will whine about how losing several million in one go is way too much and therefore isn’t fair. The US system is based almost entirely around those that already have money
@@Louis_MarcotteShould? Absolutely. Unfortunately, there’s no way that law would get passed since every lobbyist under the Sun would shovel money hand over fist to stop that from happening.
If a business is taking the cost of legal fines into consideration as part of their operating budget, should that business be allowed to continue breaking the law even if they're paying the fines on time and in full?
@@LexYeen I don't see why businesses would stop after the government tells them to... what's the gov. Gonna do? Fine them? Also no one is "allowed" to break the law. That's why there are laws: to be followed, that's why there are fines: to punish. I'm simply saying the fixed fine system doesn't work. Give a percentage of brute income as a fine and tax brute income as well
This whole process, requiring multiple specialized people (pharmacists, doctors) to go back and forth and do paperwork to accommodate the request of the insurance seems very efficient!
I mean, as Dr. Glauc pointed out in another of these videos, they don't even open medical files before denying treatment. I'm not at all surprised they tried to get your patient to try stairs. 🙄
This is absolutely true! I work at a doctors office and these are the conversations that happen every single day! Then the prior auth can take a week or more for insurance to "approve" it..the poor patient hopefully has lived long enough to get their "approved" meds or is now well and doesn't need it anymore
Yes to all of this! So sad and awful but so true!! I have experienced this exact thing with insurance with my son's medication, so frustrating for us and for the Drs I'm sure! Thank you for making this series!
So true, the only thing missing is the agent saying “oh my computer is so slow,” takes a puff of cigarette. Kid runs by screaming. After you have given all information, this is recorded the agent ask “could you repeat that?”
so glad for the medical system in Australia...and the pharmaceutical benefits scheme...it's about 15 Australian dollars or so to get a salbutamol inhaler..my pharmacist was talking about how expensive simple medications like insulin is in the US...
I remembered having moderate/severe asthma 20 years ago and being on all those meds! With terrible insurance. Back then it was at least $200-$400 per month I paid for those things as a college student. Price of breathing I guess...
Whenever I get a little hypotensive, your healthcare skits always bring my systolic BP right back up to the low 200s 😂 Thanks Doc Glauc for sharing the inside perspective of the US Healthcare system and keeping my kidneys perfused!
Sad part this is true. I've had so many conversations like this while I was in Family Medicine it made me leave. Now in urgent care and it's a little better, but I'm back in school only 5-years post grad getting my computer programming degree. We as providers, yes even us Mid-level providers aren't helping our patients, we pander to the the insurance companies whom get kick backs from big pharma. Not worth it being a medical provider.
Well as a career computer programmer/analyst, I can't say our field is frustration free, but it's probably not on the same scale as what you've dealt with. For me it wasn't the actual programming work, it was the idiotic, unethical and unreasonable clients. But I worked 95% with the government sector. My yearlong stint in medical sector software was quite the wakeup call, those clients were quite easy to work with and didn't get bent out of shape on immaterial issues and had no trouble giving us time to resolve a real problem.
I'm a nurse but work in medication safety and pharmacy transformation in my hospital in the UK, as part of transformation I'm involved in cost-effectiveness. This is literally the opposite of what we do here. There are only certain products you prescribe by brand name (usually biologics, insulin and a few particular brands with variable absorption, especially in their modified release versions. No wonder US healthcare is so expensive. It's ridiculous.
Anthem BCBS said that despite the need for morphine to manage her pain, they weren’t going to cover my 10 month old’s craniofacial surgery because she “only needed a little bit of morphine” therefore her recovery went smoothly (it did not)
Are you FUCKING SERIOUS??? A "little bit" of morphine for a BABY?? What did they expect??? So many stories I hear about insurance denials, it's like they don't listen to their own words! I'm so sorry. I had craniofacial surgery and reconstruction when I was an infant, and the stories my parents have told me about everything they had to go through... it sounds like it's really, really hard and really incredibly scary. I hope you and your family are doing okay, considering the circumstances. Sending love to your daughter.
my first time ever calling united health care was over literally this. my pharmacy told me they don't cover the generic of my medication, only the brand name. and I obviously said "but they are an insurance company and the generic is cheaper. how can this possibly make sense for anyone." pharmacist didn't have an answer. I guess they don't teach organized crime in pharmacy school.
As an asthmatic and a Family Medicine RN this is my reality both personally and professionally. This year was the first time the generic version of Symbicort was covered by my insurance. And every year we need to submit a PA for my rescue inhaler. Although miracles of miracles I once was granted a 5 year PA, only to have my employer change insurance providers the next year and back we go on the PA merry -go-round.
Excellent and hilarious and depressing as always, but I just have a quick soapbox to jump on - Qvar only comes as a breath actuated device (you flip open the lid, put the end in your mouth, and take a hard deep breath) and not an MDI (the classic pump or puffer inhaler). This means that it can't be used with a spacer AND that it requires much more negative inspiratory force to get the medication out - it is frequently insurance preferred but just does not work in kids younger than 8-10ish, kids with any muscle weakness, or kids who have to use facemask spacers.
This is what use to give me nightmares in retail. The first of the year was always the best time of the year to see how insurance was going to roll the dice.
I worked as an MA for a pulmonologist. A lot of time was spent calling the pharmacy, the indurance compny, the patient, etc etc just to get prescription filled. Insane.
Maybe I’ve just had a series of really crappy pharmacies but I’ve been on regular medications for different issues between 3-10 years for chronic health issues now and I think maybe 10 times a pharmacy has actually been willing to help me work my Dr and/or insurance it’s basically just “your insurance won’t cover this good luck” and then I get to sit on hold for a hour or two with my insurance while playing phone tag with my provider
I've found that the level of service I've received from different pharmacies has been miles apart. I've had many that are like "lol good luck," and a few that worked their butts off to get me my medication at a reasonable cost and in a reasonable timeframe. But the latter are far more rare. I distinctly remember the first time a pharmacist called me to ask, "Hey, are you aware of how much this medication costs?" It completely blew me away. I'd had so many moments of arriving to pick up a med only to find out at the counter that it costs hundreds of dollars, if not over a thousand. To instead have the pharmacy go out of their way to WARN me ahead of time... and then give me advice for how to deal with it... I think I got teary-eyed.
In Spain you can go to te doctor, who will see you for free and prescribe the medications electronically in your public healthcare card. You show this card in the pharmacy and they give you the meds for free. Some medications are not included but the 95% are. I dont even know whats a prior authorization Such a GOOD healthcare system here 🇪🇦
I have been through this! Plus the pharmacy’s system updated immediately so the generic was not covered but took a half a month for the system to cover the new drug!
As a pharmacy tech in SK Canada, generics will always be covered over brand name because they're cheaper for the government (sometimes they cover in the case of large manufacture shortages).
Had the insurance company refuse to cover a medication that had been working for a year. Said I had to fail three others first. One I had a contraindication for, one wasn’t approved to treat the condition, the third they wouldn’t cover but required me to fail first. I “failed” it because it was unattainable. Thankfully my doc reported to insurance I had failed that third option as well and they went on covering the original medication. Absolutely ridiculous!
These videos makes me glad I don't live in the US, but also makes be depressed that people in the US have to go through so many holes just to get the medication they need...
Viewing this from Quebec, this all seems really strange. The only time I've talked about generic/brand medication is when a pharmacist suggested me to switch to a generic when a doctor prescribed a brand one so I would pay less (the public insurance usually covers the generic, and you have to pay the balance if you go with the brand name)
Having worked in insurance pricing, I had and still have no idea which drugs were on what formulary for which plan. For all I know the dartboard method could be what they're using.
I'm on Flovent (because Budesonide didn't do jack for my breathing problems.) A couple of weeks ago I got a refill (from mail order which you've covered before) and it was a generic.
This one was so accurate, I actually couldn't summon the humor to laugh. This is actually how medicine is. Patients, pharmacists, physicians ... we're all the losers here in the American "health" "care" system.
Meanwhile in the UK, we were actively taught in medical school to prescribe the generic drug and avoid the brand names because it's cheaper (unless if it's one where the formulation matters).
Objection: Generics sometimes do use different "stuffing". Your medication might be a few micrograms. But to get it safely down to your stomach might take a gram of filler. One way generics are cheaper is using cheaper stuffing (think hypo-allergenic earrings). Same medication, different pill. Generics are fine for most people. But some people will be sensitive to different stuffing. So some people have immense problems with certain generics. Or it's possible they're allergic to a name brand and fine on the generic. Which is to say this whole thing is dumb and patients and doctors should have the final say. But hopefully if you follow this channel you know that. So generics aren't "just" cheaper. They usually have different allergy profiles.
@@Madamchief -- Look up the ingredient lists for various manufacturer's versions of specific drug. The binders, fillers, food dyes, and so forth can vary from manufacturer to manufacturer, even amongst generics, made by five or 10 different companies. And every so often you have a patient who doesn't have an allergy to a specific drug itself, but to one of those binders or fillers. For example, many of the fillers are wheat-based or corn-based, and you have to be very choosy about which generic version they get if your patient has a wheat allergy or corn allergy. In general, I don't care which generic version of a drug my patient gets, unless I know they have an allergy to a common filler or binder or dye. Then I make sure to add extra comments on the Rx to the pharmacist about how the product dispensed must not contain ____. And as the original poster mentioned, you can also have differences in absorption from brand to brand. That information is harder to find, and you basically will have to do a PubMed search or use some other database for the medical literature to find studies where they compare different manufacturers drugs in a laboratory setting to measure dissolution rates and what have you. As a general rule, outside of allergy concerns, most drugs that are available in a milligram or gram level of dosing are going to be OK no matter which generic version you get because the allowed 80% to 120% active ingredient ranges are going to be within the tolerances of how that medication works in the body. But there are some exceptions, even for drugs in those mg dosing ranges, with certain types of anticoagulants coming to mind. But once you are talking about a medication where **microgram** dosing is in play (such levothyroxine or birth control pills) that 80 to 120% tolerance range can make a HUGE difference in both side effects and overall efficacy. In those cases, I don't care if a patient starts on a generic version, but I want to make sure going forward they get the **exact same generic manufacturers version every single time** so we don't have to worry about their dosing being effective from month to month.
Then after the prior auth that they STILL make us do even when we write for that brand-name Rx on the formulary - the co-pay for that now allegedly "covered/approved/authorized" brand-name drug is STILL too expensive for the patient to afford anyway. We get reimbursed nothing for the time and effort our office staff puts into generating these prior authorization requests, but at the end of the day, the patient still doesn't have appropriate treatment!
As a pharmacy technician, I gotta say that everything here was spot on! Except for how quickly they were able to talk to a real person at UHC
Nah, we just see the jump-cuts. This whole process took at minimum 6-8 weeks. Most of it was pharma bro waiting on hold.
real people have soul and empathy, the only real people at UHC is clearly jimothy
As someone who used to work in office (I'm remote now and don't do anything with medications), the other inaccuracy here is the doctor never speaks to the pharmacy rep, he's too busy. One of the nurses does it (or worse, front desk) and there's a series of interactions between doctor and nurse before we get back to the pharmacist. That, or we do it all over fax and it takes up to 72 business hours for the doctor to approve a brand change.
Hence, the "you're welcome for me answering this call"
This is why I encourage people to use Cost Plus .. as long as they have your product then its going to be cheaper
As a retail pharmacist, I can CONFIRM this is what we doing everyday. Calling doctors and change to insurance perferred. God damn US Healthcare
As a non-American I must ask: messed up insurance system aside, if this is the case, why can't doctors just provide a list of all suitable options for a medication and pharmacy/patient/insurance company/whoever can pick whichever brand they prefer.
Here (Estonia) the doctors can write whatever brand they wish. The pharmacist is also legally obliged to offer alternatives with the same active ingredient.
I mean, yes, the legislation arose because pharmacies and doctors were rumored to be getting kickbacks...
@@Lightn0xdoctors deal with different insurance companies. Insurance companies will only cover certain treatments or drugs depending on the patients plan. It was as simple as you'd say, they'd do it. No one would want to do all this to and fro with the insurance company. It's v annoying and takes up a lot of time.
I live in the UK. Don't get me wrong, the NHS isn't perfect but my auntie does live in the US and this is how she described it to me. So in the UK, doc sees patient and doesn't have to think about whether or not a patient can be given a test, meds etc. Just see and treat. In the US, my auntie first has to find out which docs she can go to from her insurance, then if any investigations or meds are needed, need to find out if it's covered by the insurance and even then, it'll all be based on certain circumstances. It's just long. Even ambulances cost. Where she lives, there's a 50/50 chance that if she calls an ambulance, the company the ambulance belongs to may not be covered by get insurance. There's no way of knowing. It's a mess. I thought paying would mean faster treatment and better health outcomes but that's not the case
@@Validoleits the same in Denmark. This just seems weird to me.
This opthamologist is waging war against for profit healthcare one short at a time and I am here for it.
I'm all for that. Now I'm waiting for the good doctor to explain to everyone why ophthalmologists get paid so much more for routine procedures (e.g. cataract surgery that can be performed almost assembly-line in outpatient centers) than than those done by surgeons in other specialties requiring just as many years of training. Going further, why are procedures of almost any type compensated so much more than similar time spent with patients?
Watch, he's gonna get a cease and desist from UHC
It shouldn't be called "for profit", it should be called "pro death" or "misery and suffering friendly". Let's call it what it really is...
@@ronaldmcyr156 Exactly what they want. Everyone whining about the other guy gets a little more here or there while they control the billions extracted for providing no care at all. We are being hit with mortars and this is like complaining that the other guy in the foxhole with you took the bigger apple in the chow line.
Sadly it means s nothing in the face of literal billions of dollars in lobbying & campaign contributions (aka bribes).
The American people are (on average) too simple minded to accept a universal healthcare (or even insurance) solution because "communism". Obama didn't help any with his stupid remarks of "you can keep your doctor" when many could infact not keep their doctor thus poisoning the idea of universal health insurance even further.
Love me that "not" blatantly illegal stuff US insurance can do!
It's not illegal if they've bought the laws! 🙃
sad, but true@@LexYeen
“Blatantly” being the key word.
It's not necessarily illegal. The company gives the insurance company a rebate. If the patient hasn't reached their deductable they have to pay full price and the insurance company pockets the rebate they received.
There is no law that the insurance company has to pass on the rebate to the consumer, so this entire thing is legal
@@bonnome2
yeah thats the fcking problem, bud.😂
That "it's almost always bad news" line hits home. Pharmacy gets stuck as the middleman between everyone.
We’re always the bad guy. Punching bag for everyone else.
I worked retail pharmacy for about a year. I couldn't do it. It broke me mentally. My anxiety and depression couldn't handle always being the bad guy. I remember having to tell a desperate father that I couldnt dispense the medication for his sick child 3 days in a row because something kept getting rejected about the prescription every day. I just couldn't do it.
@@Oriansenshi
What a good soul
It wasn’t you fault
I always do my very best to be nice to pharmacists and techs for exactly this reason. Especially when they give me bad news. I know they have very little control over this bullshit system and there is no point in shooting the messenger. 😕
try be a nurse, u got all that and get to meet the doctors, patients, and angry insurance agents in person! fun stuff really
I'm a pharmacist in the USA and I can vouch that this is LITERALLY what I deal with every day.
Tragic
I have hit this never ending stream of new prior authorization needs for basic meds in the last couple months through my clinic. It is eating up about 5 hours per week which is all the "admin" time I'm allotted for extra charting. Our volume went from about 25/day to 45/day as of last week and we dropped down to one PA or NP covering that portion of our clinic.
Haven't been able to play with my son at night for 2 weeks due to getting home right at bedtime.
I hate how our healthcare is run. I just want to raise my family and help people.
Man that sounds horrible! I'm in a government run healthcare (Denmark) and there sure are downsides. But it seems a lot better then the us system 😢
Seriously I’ve been getting PAs for fibrates. Like why do you do this to me?
that's how soul music was born
I'm a state employee with "gold plated" health insurance, and I still have to navigate this bull$hit
@@liberalsockpuppet4772
"plated in 10k gold is still gold plated!" - them, probably😅
I used to work in a pharmacy and this was an almost daily occurrence. It’s insane how long I’d spend on the phone with people who either said “we don’t cover it anymore” or “you need a prior authorization”.
What is a prior authorization please?
@@BahamariaInsurance requires detailed paperwork from the doctor in order for the insurance to actually cover the med - basically insurance yelling "make me" and running away forcing the doctor to chase after the coverage
@@Bahamaria It is the second prescription your doctor has to send to the insurance after they didn't believe the doctor just sent the first prescription... AKA a great way to kick a bill just a little further down the road if not discourage patients from trying to be healthier all together
As a US pharmacist, the pain of this video is all too real. The only thing is he missed the "oh, now you have to pay a brand name copay for the drug that we won't cover as the generic". So now they have a $100 copay on brand name med that the generic costs $45 cash.
That's about to happen to one of my meds. The patent JUST expired like a month ago, and the brand name manufacturer started ramping down production even before the expiration. So now you can't find a pharmacy with either the brand name or generic in most doses. Had to call 30 different pharmacies to find one that had a close enough dose and got my doctor to lower my dose and send it to that particular pharmacy. (Not a "live or die" medication but an improved QOL med.) I know my insurance will cover name brand, but they haven't updated the formulary yet to cover generic. The brand name is over $400, but they also have a $60 coupon, so my copay usually ended up around $45. No clue yet how much the generic will be cash because no one can actually get it lmao. I've hit my OOP max for the year tho, so I'll take the brand name from now on just to force the insurance to update their formulary quicker, lol.
United health loves it if you decide to skip insurance for the lower cost generic. They still keep your monthly premium and don’t have to pay for your drug!
@@wolfoftheagesUnfortunately, from experience, the generic becoming available doesn't save you money immediately... It MIGHT be cheaper, but only just. It takes a few years before the costs settle into being actually reasonable.
@@wolfoftheages I know exactly what med you are talking about. 60 and 70mg are non-existent, one patient told me they called every pharmacy in the city and no one had any. Good thing is the backorder on the generic extended release for the OG drug in the class is finally starting to ease up and we've been able to get a few bottles here and there.
Can a customer just say ok I'll just buy the generic? An insurance company tried that on me and I was like ok out of pocket it is- it's cheaper for me anyway
Politicians: but we can't nationalise health care. The government is so inefficient.
US: Spends far more on administrative costs related to healthcare than any other nation because of how hard it is to order medication.
Also they scream "communism" any time you go near Healthcare despite the fact that Europe and Canada do it nicely.
Translation: "We won't make nearly as much money if we don't keep taking bribes from insurance companies."
@@Giantcrabz Yup, over time you realise this ... we need politicians that are brave enough to switch to the German system
@@strawdemindsetit would help if people stopped being brainwashed into the 2 party system. But I think there's a higher chance of 15 or more generations dying and\or the sun exploding before that happens
@@strawdemindset Oh, please, don't choose model our system, it's in the process of being eroded and ever more privatized to make it more like the USA's. Please choose one of the Nordic countries.
“PHARMACY! It’s so good to hear from you, even though it’s almost always bad news.”
Oh Paediatrics, always being the most upbeat about any situation.
As someone starting medical school in the UK, I'm studying this series carefully so I can get a handle on the way prescribing will be over here in 10-15 years. Thanks for the course. How much do I owe you?
One strike action against the forces corrupting healthcare.
In fairness I don't think it would be as bad as this even if we completely shove the NHS out the window. Our laws tend to be more consumer protective so things like insulin prices would be more likely to remain ok. That said I'm also starting med school in the UK and I am also getting myself familiar with these things just in case lol
People have been saying the NHS will be replaced by a US style system since Clement Attlee lost in 1951 it hasn't happened because no one wants a US system.
But you do know you have to pay in many EU countries right? especially for non emergency care.
The simple fact is the number of workers per retirees (who need the most medical care) is going down so it's either more tax (which can be diverted by governments) or personnel insurance the best thing today is clearly set up a government started but not run by (like the BBC) insurance trust for those just entering the jobs market that will be used to fund long term care and medical expenses either dur to age or accident related issues.
Normal A&E can be kept as free tax funded but any long term meds or care can come out of a persons personnel insurance.
Raising taxes is a dead end as people don't want it hell look at anyone who works as a contractor when the government wants building work done they take 10 times as long and charge 10 times as much because they want to get their tax back ignoring that the tax is supposed to pay for running the country.
@@Ushio01you need to do more punctuation, but thanks for the comment
One of the greatest assets that the NHS has is being able to negotiate on drug prices. They even have a hard limit for the amount they'll pay for a certain amount of benefit. This means that pharma companies can't make runaway profits in the UK and *that* is what the Tories actually want to change. So increasing taxes or not actually doesn't have much to do with it.
I "love" that we're 13 days into 30 days of us healthcare and they've all just been about trying to pay for it.
because that's actually where we are a third rate banana republic. the quality of care for those who can afford it is not the issue with American health care.
if money isnt a factor, american healthcare is pretty good, so youd find it difficult to talk much about it in that regard
its just that money is a factor for anyone who isnt a mulitmillionaire
Pharmacist here. I’ve just been triggered!!! 😱😱😱 The accuracy of this vid is astounding & horrifyingly true ~ except at how fast this can be done!! I’m so glad I’m retired now!! 😂😂😂
My favorite is after doing a prior authorization for a prescription, the insurance company turns around and says, “Just kidding, we really didn’t need that! We just hoped you’d give up and not make us spend any of the patient’s money.”
🎵 "Surprise! You're on Candid Scamera!" 🎵
As frustrating as that unnecessary runaround is, at least in most of those cases the medication still gets covered. Sometimes you switch to the formulary approved drug, do the perplexing prior authorization that they STILL require even though you picked the formulary drug, and then even though it's covered, the co-pay is too expensive for the patient to afford anyway!
Great summary. A hidden cost here people don't see is we just wasted precious time of a pharmacist and pediatrician for non-direct patient care items. Another thing that increases healthcare costs.
Thank you for putting these people on blast for an entire month. Wish more doctors would speak up like you
They would if they weren't stuck struggling with this bs in clinic
Family medicine doctor here. This is so accurate it literally made me feel a bit sick 😢
[Screams of anguish] I take Qvar. My pulmonologist writes my prescription for two puffs twice a day instead of one so I hit the 90-day medication maximum for three inhalers instead of having to buy them one at a time for maximum price. (They can't give me two for the 90-day price because that would be 120 days of meds and you can't have more than 90. Never mind that I've been taking these meds for decades.)
I feel this in my BONES. Well... lungs.
Asmanex is the only asthma control med that works for me. It works amazingly with zero side effects. I've tried *everything else*. Either horrible side effects, doesn't help, or actually makes asthma worse. My doctor and his staff have wasted so much goddamn time writing appeals for me... for a medication that's worked since 2006.
Caremark eventually covered it kinda. But for some reason I can't get the full dose I need. When I'm having a flare up I'm supposed to take 220mcg twice a day. For some reason, I can only get 30 doses of 110mcg, or 14 doses of 220. Soooo a quarter of what I need.
My doctor did some gymnastics and got me two 14 dose 220 twisthalers this last time. They took a few weeks to get in to my local CVS. I need them. But I'm too scared to use them now, bc I know I'll need them more critically if I have a virally induced uptick in asthma and it'll be really hard to get. Sooooo yeahhh...
Oh, and my kid takes symbicort, and we both have epi pens. Just...yaknow..adding to the fun.
It's like they'd rather people die from life threatening but easily treatable things than actually let us be treated by the meds our doctors know work for us. It feels like a eugenics loophole tbh.
@@WxBugginOhhh, you said the quiet part out loud!!
No but seriously, some of the shit that's being pulled in the healthcare industry absolutely hurts the sickest people worst of all. The word "eugenics" has certainly crossed my mind as well.
Keep it up Doc. I’m showing these to everybody that will watch. Great stuff.
You just made my month Doc! Almost enough to make me forget that I owe 2000 for a single X-ray after a babysitter thought my 1 year old swallowed a button battery and my insurance only covered 600 even though this happened in late September because our deductible was not met. Hopefully Jimothy can make a difference.
Me too! Aetna = Same
The most absurd part is when the insurance will only cover brand, but the brand *copay* is higher than the *self-pay* price for generic. Which in my experience as a pharmacist seems to be about half the time these kickback shenanigans are in play.
Shouldn't you just take the generic then?
If the generic cost without insurance is lower than the brand name *with* insurance, why would you still take the brand name?
@@raznaakit's hard to know ahead of time. Only very very few pharmacists will bother to calculate _both_ prices and see which one is lower. Dunno if it's a software thing, time issue, apathy, or a bit of all of them.
I've personally experienced this when a pharmacy called me to say that insurance wouldn't cover it for x, y, and z. I said, well, what's the price without insurance? It was something ridiculous like $5. I said, why are u even calling me?? Just fill it and tell me I get a good customer discount 😂
That's the point, either you pay for brand which gives them kickbacks or you pay oop generic which saves them money... They literally can't lose there
@@kap4020 huh.
For all the medications I took (not much mind you, but still some), the pharmacist told me my options before I pay.
Like, when my doctor prescribed me a brand name, the pharmacist told me I could pay X for it, but Y for the generic that works the same for what I needed.
Granted, in Québec we have a public medication insurance that covers generics better than most brand names but still...
How it works here: all non-medication healthcare costs are always covered by the public healthcare that is comprised within our taxes (except of course teeth, they're still luxury bones here too). Medication given to you in a clinic or hospital are also covered while you're there, but once you're out you pay for the prescribed medication.
The public medication insurance is ~600$ per year included in your taxes declaration and covers like 20%-80% of the prices of medication depending on many factors (which are already peanuts compared to the USA but still not that cheap sometimes).
You can choose to opt out of it and the 600$ of taxes, but you MUST prove you have a private insurance, no one is allowed to be uninsured.
Private insurances work basically the same as other insurances, so minimum amount before they start to pay, they can refuse to pay depending on your plan, and many other problems...
If you don't have a lot of medication to take, public insurance is sufficient, but if you're in a family that takes a LOT of medications, the private insurances can be worth it on the long run.
@@raznaak-- Precisely what the insurance company is hoping is going to happen. They don't care how much time and energy is wasted doing this song and dance before the patient ends up paying out-of-pocket. And as somebody else already mentioned, we have no idea what the patient's out-of-pocket cost is going to be until after we send the Rx, the pharmacy runs it through the system, and finds out how much it's going to set the pt back. Even for generics that have been out for decades and are made by 20 different companies.
For example, about five or six years ago, the cash price for generic doxycycline -- a tetracycline derivative that has been FDA approved and on the market since **1967** -- was all of a sudden more expensive than newer antibiotics that were still brand-name only. There was some vague talk about a shortage of raw materials for manufacturing, but I never got a good enough explanation from anybody about why the price went through the roof. Doxy is back to being cheap again these days, but you just don't know what your patient is going to face at the cash register even when you write for a generic.
You have totally captured my insurance company, BUPA! I was hospitalized six months ago for two major surgeries and spent more time on the phone arguing with the company than I spent recovering. Oh, I almost forgot to mention, I spend $15,000 for international premium insurance and have too many preexisting conditions to change companies.
I'm a utilization review nurse for a hospital typing this while on hold with UHC trying to set up a peer to peer. Please do one on their phone tree and/or how they generate a million auth numbers for the same encounter. Placed in obs? One number. Updated to inpatient? Two more auth numbers. Denial? New auth number. Then when you call for a peer to peer, they're confused about which auth you mean.
Edit: when I got them on the line, they did it again. Multiple auth numbers. I figured out their game and they forwarded me to a phone tree.
The phone trees I've had to deal with the last two or three weeks have almost made me lose my mind. I swear they're just getting longer and more obtuse. Just trying to reach the same person/department you were JUST talking to shouldn't have to take literal minutes. Maybe it's saving them time, but it's killing me.
@@safaiaryu12Most of the calls go to a call center. The people who answer the phone are all spread out throughout the USA. We can’t just transfer you to Jenny because we have no idea who Jenny is. Most call centers are not equipped to do anything. The reps work from home. It’s all micromanaging by superiors. Those of us who have a soul cry on a daily basis. It’s all about numbers not people who are suffering. When you are the patient and the call center rep it’s soul crushing. It’s even worse when you clock out to get on the your cell phone to call a call center for your immunosuppressant medication to get the round around. Some of these organizations are worth billions of dollars but the patient is not a priority. If one or two people sue or worse die they still have billions and are not bothered. Supervisor’s weed out the reps that care because we are on the phone trying to find someone within the organization with a pulse to help us help the patient. It’s so sad to hear another rep tell you that’s not their problem that a medication isn’t covered or that the patient has been on the phone for days. It’s a sad state of affairs in America.
Uuugghhh, yes, the dreaded impenetrable phone tree!!!
As a nurse who helped patients with insulin, this is the TRUTH!!!!! So much time and energy that we don't have. I hope you do the "let me transfer and hand up on you 6 times" episode!
I can't imagine the ordeal of practising in the USA.
Just the other day, I gave a pt in the ER a medication that costs over 6000EUR as easy as giving paracetamol...
Be strong there! 💪
See, here in the United States, that hypothetical Tylenol® dose in the ER costs the patient $6,000 USD, so our systems are not all that different. 😢
Some of us are strong. Some of us are dead.
I want as many of these to go viral as possible. Having very specific points like this is helpful when talking to representatives.
The dartboard is urban legend .
Insurance companies use a very sophisticated computer algorithm that takes into account variability in the supply and demand ( and therefore , pricing of drugs ) of APIs for the Pharma industry .
Just kidding , they have a " Chicken Bingo " app .
The Pharma companies use dartboards to set pricing .
Sometimes I get awfully frustrated watching Dr. Glauc videos and then I remember I live nowhere near U.S. Have to actively remind myself "not my circus not my clowns" to calm down
Hope this goes viral and things change for better
I live in the USA and I don’t think things are going to get better soon.😮
No worries for you .
All the Clowns are protected by the Secret Circus anyway .
@lj-ho5wg
The Junior Doctors' strike in UK for pay restoration that's been going on for months now, started from what was essentially a series of legendary shitposting on reddit. So maybe, Dr.Glauc could be "it" for the US.
We'd have to do an entire sweep-out of our current government for things to get better.
They're not going to change anything so long as Big Pharma and the insurance industry are lining their pockets. The money speaks way louder than our votes.
imagine how frustrating it is when you DO live here. god i want to move...
I have to say as a UHC patient, this is accurate. My oncologist prescribed Zofran and they would only cover the sublingual tablets and she had to submit a prior authorization. When I went in the next time it was only the regular tablet and no orior authorization needed, but would only cover 4mg tablets, not the 8mg. And back to sublingual tablets the next time. Finally we got fed up, and she ordered the really expensive IV medications for home administration via my port, and they didn't blink an eye.
Also fun fact the only generic on the market for Flovent is manufactured by GSK the maker of the brand so they would get all of the money anyway but still incentivize insurance companies to have brand on their formulary because brand medication claims get reimbursed to pharmacies at different (usually worse) rates than generics! 🙃 And the copay is still usually asinine as well.
"...as if laws apply to the US health insurance industry..."
😂😭😭😭
Ooh! Don't forget about the part where the insurance charged the pharmacy a fee for everytime they submitted the claim only for it to be rejected with an ambiguous denial code that required a phone call to clarify!
And the part where the insurance will only reimburse the pharmacy for part of the cost of the medication. Even including the copay we loose money on ~40% of our prescriptions....BEFORE you take into account the processing fees...or over head (bottle, label, tech, pharmacist, etc).
Or the fact that they'll "say" we're going to make money on a prescription, only to come back 6 months - 10 years later and say "we over paid you so we're going to reclaim some of that money" but not tell you what claim it is for or what the random $5,000 "fee" is that we're being charged.
Or the part where the insurance owns their own pharmacy and makes getting maintenance meds at your local pharmacy so convoluted and consistently delayed, that in order to keep reliable access you have to use their pharmacy.
It shouldn't even be legal for them to be pharmaceutical insurance and the pharmacy too.
Pediatrician here and OH MY is this an accurate depiction of how this is - even with those two meds! Well done sir.
B 50 1:31.
Thank yooou this one is too real. I might start showing it to my patients when I prescribe them an inhaler so they know why it often takes a few days to get the “right” script figured out
I love your videos!! I showed my opthalmologist and he laughed out loud!
Meanwhile in Australia I walk in the pharmacy with my script. Pharmacist tells me “your doctor has prescribed a brand name med that costs $40 do you want to switch to the generic and save $10?” No need to call anyone as they are same medication and pharmacist allowed to switch brands.
Meanwhile in Japan, the government negotiates on our behalf for reasonable prices, and since medications are more straightforward here with government health insurance...our pharmacists aren't dealing with approvals and have time to consult in a meaningful way with patients about what we're taking. (No HMOs either - we choose our own doctors and pharmacists freely because nearly everyone participates in the government system.) Like all healthcare systems, there are real problems here too, but hassle free access to needed medication Japan does extremely well, and I wish it could be copied in America. You all deserve so much better than what you have.
You are going to make me cry...
Wow I always wondered why I would randomly switch between getting Flovent and QVAR! Guess I know now
@@Giantcrabz As the great comedic writer Dave Barry once wrote, insurance companies are in the business of collecting premiums, not paying claims.
“Uuunited Healthcare, you’re welcome for me answering this call”
😂😭😡
I do appreciate you helping "prior authorization" enter my vocabulary and helping me understand what it means.
These videos should be seen by every single person in Congress. Especially the ones who say that universal health care is “socialism.”
YES. Let’s write our reps and tell them. Seriously.
2/3 of them own stock in these companies.
Yeah! That's a great idea!
Hey? What the hell is that?!
Oh no! A group of Lobbyist?! We're done for!!! 😢😢😢😢
Ditto on the lobbyist and stock ownership angles that are keeping our politicians from doing a damn thing about this. We need reform in Congress, and in the Fed executive branch, and Fed judicial branch, requiring everybody to divest from all individual stocks before taking office and switching everything into an index fund. Same for their immediate families, including adult children, elderly parents, siblings, etc. And we also need to kick 75% of the bums out and replace them with people who will pledge not to take money from lobbyists.
It IS socialism but that is a good thing.
I love watching these. Makes me feel so lucky I live in a country with universal public health care.
We are so jealous! Lol lucky
Lucky you, America only wants to make money, no room for social services.
When you are making billions, legal fines are just a cost of doing business.
Should probably adjust the price of the fines, it doesnt matter how much you're making if the fine's 50% of what you got :)
@@Louis_Marcotteyes but then the scumbags will whine about how losing several million in one go is way too much and therefore isn’t fair.
The US system is based almost entirely around those that already have money
@@Louis_MarcotteShould? Absolutely. Unfortunately, there’s no way that law would get passed since every lobbyist under the Sun would shovel money hand over fist to stop that from happening.
If a business is taking the cost of legal fines into consideration as part of their operating budget, should that business be allowed to continue breaking the law even if they're paying the fines on time and in full?
@@LexYeen I don't see why businesses would stop after the government tells them to... what's the gov. Gonna do? Fine them?
Also no one is "allowed" to break the law. That's why there are laws: to be followed, that's why there are fines: to punish.
I'm simply saying the fixed fine system doesn't work. Give a percentage of brute income as a fine and tax brute income as well
This whole process, requiring multiple specialized people (pharmacists, doctors) to go back and forth and do paperwork to accommodate the request of the insurance seems very efficient!
I ran into this on a formulary yesterday. Thanks for shining a light on companies doing the wrong thing for patients.
Reminds me of the time insurance wouldn't approve my patient for SNF until they'd attempted stair negotiation. They were bilaterally nonweightbearing.
😂/😢 it's just nuts.
"Yep, we ran their wheelchair into the stairs and they failed to stand up and negotiate the stairs whilst being non weight-bearing bilaterally. 😂
OMG. I guess they were hoping Pt would fall down the stairs and die, thus solving their problem.
I mean, as Dr. Glauc pointed out in another of these videos, they don't even open medical files before denying treatment. I'm not at all surprised they tried to get your patient to try stairs. 🙄
This is absolutely true! I work at a doctors office and these are the conversations that happen every single day! Then the prior auth can take a week or more for insurance to "approve" it..the poor patient hopefully has lived long enough to get their "approved" meds or is now well and doesn't need it anymore
No kidding, bladder infections, “we have to send this to a lab, we will get results in 3-5 days” I will kill myself by then!
Yes to all of this! So sad and awful but so true!! I have experienced this exact thing with insurance with my son's medication, so frustrating for us and for the Drs I'm sure! Thank you for making this series!
It just warms my heart to know someone else understands my pain.
These should be going viral... Extremely informative and real... Real depressing.
You want them viral? Copy/paste to 5 friends!
So true, the only thing missing is the agent saying “oh my computer is so slow,” takes a puff of cigarette. Kid runs by screaming. After you have given all information, this is recorded the agent ask “could you repeat that?”
Side note but I love the marker in place of the headset mic, smart!
Pharmacy it’s so good to hear from you even though it’s always bad news. Welcome to Pharmacy in America 🇺🇸!
I REALLY hope these videos go super viral and something changes, watching these take me to dark places.
Having been an asthma and allergy specialist, I can say this is 100% spot on.😢
OMG I do PAs and benefits investigations for a pediatric pulmonology clinic and THIS IS MY ENTIRE DAY IN A NUTSHELL!
so glad for the medical system in Australia...and the pharmaceutical benefits scheme...it's about 15 Australian dollars or so to get a salbutamol inhaler..my pharmacist was talking about how expensive simple medications like insulin is in the US...
This one really hits home. Happens in my office literally every day.
Best. Series. EVER. Keep going!!!!
Bless pediatrics and their eternally positive disposition.
And this is why I pray every day for myself and my neighbors to not get sick or on medication.
I remembered having moderate/severe asthma 20 years ago and being on all those meds! With terrible insurance.
Back then it was at least $200-$400 per month I paid for those things as a college student.
Price of breathing I guess...
Whenever I get a little hypotensive, your healthcare skits always bring my systolic BP right back up to the low 200s 😂
Thanks Doc Glauc for sharing the inside perspective of the US Healthcare system and keeping my kidneys perfused!
I’m not sure if I should laugh or cry about how accurate this is. 😭😭😭 your videos are amazing
Sad part this is true. I've had so many conversations like this while I was in Family Medicine it made me leave. Now in urgent care and it's a little better, but I'm back in school only 5-years post grad getting my computer programming degree. We as providers, yes even us Mid-level providers aren't helping our patients, we pander to the the insurance companies whom get kick backs from big pharma. Not worth it being a medical provider.
This. thank you. not a single u.s healthcare provider helps their patients anymore. It's all down to the insurance and drug companies.
Well as a career computer programmer/analyst, I can't say our field is frustration free, but it's probably not on the same scale as what you've dealt with. For me it wasn't the actual programming work, it was the idiotic, unethical and unreasonable clients. But I worked 95% with the government sector. My yearlong stint in medical sector software was quite the wakeup call, those clients were quite easy to work with and didn't get bent out of shape on immaterial issues and had no trouble giving us time to resolve a real problem.
Move to a civilized country with universal Healthcare. Canada could use you.
@@chirpieone9193 A lot of us are trying.
I'm a family doctor and I have never felt more seen and heard than I do right now watching this 😭
This is literally my life as a pediatrician in dealing with insurance companies, especially United!
I'm a nurse but work in medication safety and pharmacy transformation in my hospital in the UK, as part of transformation I'm involved in cost-effectiveness.
This is literally the opposite of what we do here. There are only certain products you prescribe by brand name (usually biologics, insulin and a few particular brands with variable absorption, especially in their modified release versions.
No wonder US healthcare is so expensive. It's ridiculous.
Anthem BCBS said that despite the need for morphine to manage her pain, they weren’t going to cover my 10 month old’s craniofacial surgery because she “only needed a little bit of morphine” therefore her recovery went smoothly (it did not)
That’s outrageous. I’m so sorry you guys have to deal with that.
Actual monsters. No parent should have to go through that.
I'm so sorry
Yeah I'd be fighting that. Did they expect a 10 month old to get the same dosage as an adult? I'd be bluntly asking that question.
Are you FUCKING SERIOUS??? A "little bit" of morphine for a BABY?? What did they expect??? So many stories I hear about insurance denials, it's like they don't listen to their own words!
I'm so sorry. I had craniofacial surgery and reconstruction when I was an infant, and the stories my parents have told me about everything they had to go through... it sounds like it's really, really hard and really incredibly scary. I hope you and your family are doing okay, considering the circumstances. Sending love to your daughter.
Incredible this is happening consecutively. Normally it takes days if not weeks between each call.
the timeline is accelerated for dramatic effect.
my first time ever calling united health care was over literally this. my pharmacy told me they don't cover the generic of my medication, only the brand name. and I obviously said "but they are an insurance company and the generic is cheaper. how can this possibly make sense for anyone." pharmacist didn't have an answer. I guess they don't teach organized crime in pharmacy school.
Or the pharmacist didn't want to say anything that could come back to bite them later.
the pharmacists knows exactly what is going on. They LOVE this. They LOVE torturing patients and doctors. They are GLAD this is going on.
As an asthmatic and a Family Medicine RN this is my reality both personally and professionally. This year was the first time the generic version of Symbicort was covered by my insurance. And every year we need to submit a PA for my rescue inhaler. Although miracles of miracles I once was granted a 5 year PA, only to have my employer change insurance providers the next year and back we go on the PA merry -go-round.
In South Africa we have free healthcare at all levels of care, including surgery, for all citizens…
Excellent and hilarious and depressing as always, but I just have a quick soapbox to jump on - Qvar only comes as a breath actuated device (you flip open the lid, put the end in your mouth, and take a hard deep breath) and not an MDI (the classic pump or puffer inhaler). This means that it can't be used with a spacer AND that it requires much more negative inspiratory force to get the medication out - it is frequently insurance preferred but just does not work in kids younger than 8-10ish, kids with any muscle weakness, or kids who have to use facemask spacers.
Yeah I sure love being the healthcare equivalent of the kid who has to pass messages between divorced parents who aren't speaking.
This is what use to give me nightmares in retail. The first of the year was always the best time of the year to see how insurance was going to roll the dice.
As a pediatrician I felt this sooo hard.
Thank you for making these shorts, I absolutely love them! Please keep speaking truth to power.
My goodness, I am learning a lot from this series. Thank you for sharing!
I worked as an MA for a pulmonologist. A lot of time was spent calling the pharmacy, the indurance compny, the patient, etc etc just to get prescription filled. Insane.
Maybe I’ve just had a series of really crappy pharmacies but I’ve been on regular medications for different issues between 3-10 years for chronic health issues now and I think maybe 10 times a pharmacy has actually been willing to help me work my Dr and/or insurance it’s basically just “your insurance won’t cover this good luck” and then I get to sit on hold for a hour or two with my insurance while playing phone tag with my provider
I've found that the level of service I've received from different pharmacies has been miles apart. I've had many that are like "lol good luck," and a few that worked their butts off to get me my medication at a reasonable cost and in a reasonable timeframe. But the latter are far more rare.
I distinctly remember the first time a pharmacist called me to ask, "Hey, are you aware of how much this medication costs?" It completely blew me away. I'd had so many moments of arriving to pick up a med only to find out at the counter that it costs hundreds of dollars, if not over a thousand. To instead have the pharmacy go out of their way to WARN me ahead of time... and then give me advice for how to deal with it... I think I got teary-eyed.
In Spain you can go to te doctor, who will see you for free and prescribe the medications electronically in your public healthcare card. You show this card in the pharmacy and they give you the meds for free. Some medications are not included but the 95% are. I dont even know whats a prior authorization
Such a GOOD healthcare system here 🇪🇦
I learn so much from these videos
I have been through this! Plus the pharmacy’s system updated immediately so the generic was not covered but took a half a month for the system to cover the new drug!
As a pharmacy tech in SK Canada, generics will always be covered over brand name because they're cheaper for the government (sometimes they cover in the case of large manufacture shortages).
Had the insurance company refuse to cover a medication that had been working for a year. Said I had to fail three others first. One I had a contraindication for, one wasn’t approved to treat the condition, the third they wouldn’t cover but required me to fail first. I “failed” it because it was unattainable. Thankfully my doc reported to insurance I had failed that third option as well and they went on covering the original medication. Absolutely ridiculous!
"we need you to try morphine!" Motherfuckers, morphine makes me go into anafalaxis. you don't want that!
These videos makes me glad I don't live in the US, but also makes be depressed that people in the US have to go through so many holes just to get the medication they need...
I love this idea and your work
But it’s painfully true
It’s incredible
Viewing this from Quebec, this all seems really strange. The only time I've talked about generic/brand medication is when a pharmacist suggested me to switch to a generic when a doctor prescribed a brand one so I would pay less (the public insurance usually covers the generic, and you have to pay the balance if you go with the brand name)
Having worked in insurance pricing, I had and still have no idea which drugs were on what formulary for which plan. For all I know the dartboard method could be what they're using.
This became my routine after I come back from work
I'm on Flovent (because Budesonide didn't do jack for my breathing problems.) A couple of weeks ago I got a refill (from mail order which you've covered before) and it was a generic.
I have just gone through this EXACT scenario specifically with Qvar and Flovent for my child. I hate how accurate these are...in a good way.
This one was so accurate, I actually couldn't summon the humor to laugh. This is actually how medicine is. Patients, pharmacists, physicians ... we're all the losers here in the American "health" "care" system.
this makes me think guillotines will be back in fashion soon.
Meanwhile in the UK, we were actively taught in medical school to prescribe the generic drug and avoid the brand names because it's cheaper (unless if it's one where the formulation matters).
I knew it 🤔
Your dialogue is always outstanding, (and hilarious)
Oppppp you saying the quiet stuff outloud!!! And I love it.
Objection: Generics sometimes do use different "stuffing". Your medication might be a few micrograms. But to get it safely down to your stomach might take a gram of filler. One way generics are cheaper is using cheaper stuffing (think hypo-allergenic earrings). Same medication, different pill.
Generics are fine for most people. But some people will be sensitive to different stuffing. So some people have immense problems with certain generics. Or it's possible they're allergic to a name brand and fine on the generic. Which is to say this whole thing is dumb and patients and doctors should have the final say. But hopefully if you follow this channel you know that.
So generics aren't "just" cheaper. They usually have different allergy profiles.
I have to have brand-name Levoxyl. Any other brand/generic just flat-out doesn't work. I've had to argue this EVERY TIME I renew.
Source?
@@Madamchief -- Look up the ingredient lists for various manufacturer's versions of specific drug. The binders, fillers, food dyes, and so forth can vary from manufacturer to manufacturer, even amongst generics, made by five or 10 different companies.
And every so often you have a patient who doesn't have an allergy to a specific drug itself, but to one of those binders or fillers. For example, many of the fillers are wheat-based or corn-based, and you have to be very choosy about which generic version they get if your patient has a wheat allergy or corn allergy.
In general, I don't care which generic version of a drug my patient gets, unless I know they have an allergy to a common filler or binder or dye. Then I make sure to add extra comments on the Rx to the pharmacist about how the product dispensed must not contain ____.
And as the original poster mentioned, you can also have differences in absorption from brand to brand. That information is harder to find, and you basically will have to do a PubMed search or use some other database for the medical literature to find studies where they compare different manufacturers drugs in a laboratory setting to measure dissolution rates and what have you.
As a general rule, outside of allergy concerns, most drugs that are available in a milligram or gram level of dosing are going to be OK no matter which generic version you get because the allowed 80% to 120% active ingredient ranges are going to be within the tolerances of how that medication works in the body. But there are some exceptions, even for drugs in those mg dosing ranges, with certain types of anticoagulants coming to mind.
But once you are talking about a medication where **microgram** dosing is in play (such levothyroxine or birth control pills) that 80 to 120% tolerance range can make a HUGE difference in both side effects and overall efficacy. In those cases, I don't care if a patient starts on a generic version, but I want to make sure going forward they get the **exact same generic manufacturers version every single time** so we don't have to worry about their dosing being effective from month to month.
Then after the prior auth that they STILL make us do even when we write for that brand-name Rx on the formulary - the co-pay for that now allegedly "covered/approved/authorized" brand-name drug is STILL too expensive for the patient to afford anyway. We get reimbursed nothing for the time and effort our office staff puts into generating these prior authorization requests, but at the end of the day, the patient still doesn't have appropriate treatment!
Insurance company: SCORE!!!
😂 I have multiple times this week played the insurance dartboard game with the inhalers. Too poignant!