James E. Waun, MD, MA, RPh

The mood of passive resignation punctuated by angry cynicism in healthcare is reminiscent of the old self-serving, inefficient Soviet bureaucracy. 

It is a routine day in a pharmacy adjacent to a mid-size hospital in a small city in an ordinary state. This is typical 2008 healthcare.  

When she hears the drug is going to cost nearly $200 this time, she says in a quiet voice seething with anger, "The last two times it cost $30. Why can't you people get it right? I wouldn't ever come here if I had a choice." (Her insurance pays for drugs only at our pharmacy.)  

We explain we bill insurers online. They tell us how much to charge patients; we have no say in the matter. We make the first of 10 uncompensated calls to insurers that day, each taking at least 15 minutes and some lasting up to 45 minutes, to see what can be done.  

The insurance clerk says there is a $119 penalty added to the cost of the prescription because mail order wasn't used. (Insurance companies set the rules. They also own mail-order pharmacies.) They reduce our payment by $119, so we don't get any more money.  

As we tell her the bad news, her voice returns to normal. She tells us that when she called the insurance company yesterday, they told her they don't stock the drug, so she'd have to get it at her local pharmacy. They wouldn't talk with her about the medication further. 

Our staff consoles her for 10 minutes. Then she goes to a pay phone in the hall and doesn't return. Did she abandon her slim hope of having a baby? Did she persuade her insurance company to send her the drug? If so, she's in for at least another two-week delay, and another wasted menstrual cycle. After the doctor sends the mail-order pharmacy the prescription, she sends them the payment, and then they send her the drug.  

A little later, a mother comes in carrying her sick baby. She asks whether the prescription for her baby's wheezing is ready. Her doctor's office had faxed it to us, she said. She was told to go directly to the pharmacy, where the medication would be ready. We have no fax.  

We call the medical school faculty doctor's office, finally speak to a person and are told they need to check with the doctor to see what was supposed to be faxed, and that they will get back to us. Two additional phone calls and an hour and a half later, we get the fax and the mother and baby are finally able to leave. Fortunately, the baby is not cranky and the mother is extraordinarily patient. We are incredulous that healthcare patrons accept such terrible service.  

The day's most frustrating event begins unfolding when a man brings us a prescription for sleeping medicine written by the oncologist for his wife with cancer. She's had a nerve resection in her head that partly relieved her pain; she has a morphine pump and supplements it with other narcotics.  

With the medications, the man and wife want to travel as often and far as they can in the time they have left together. The next day they are leaving for trip to a southern state. A glitch in their plans arises when their Plan D Medicare Prescription insurer wouldn't authorize payment for the sleeping medication for two days.  

We call the insurance company and request a "vacation override," early approval for people on vacation. The insurance clerk tells us they don't do that. Apparently, seniors are supposed to be flexible enough to plan vacations around insurance company rules. 

They could take their prescription with them on vacation, but may have difficulty finding a pharmacy in a distant state willing to fill a sleeping pill prescription written by an out-of-state doctor. The man wonders why he can't get the sleeping medicine for his wife; a Kroger pharmacy filled a narcotic prescription for her the day before.  

We call the Kroger pharmacy and find they bent the rules, risking a fine to fill the narcotic prescription and then bill for it later. Our small pharmacy chain doesn't do that, so after an hour of trying to figure out what to do, we transfer the prescription to Kroger.   

is an associate clinical professor, Department of Family Practice and Adjunct Faculty, Center for Ethics and the Humanities, Michigan State University, and an adjunct assistant professor of clinical pharmacy, Ferris State University.

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Author | James E. Waun, MD, MA, RPh

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