The Pharmacy Chick

Flying the coup in retail

What if?

Filed under: Uncategorized — pharmacychick at 10:49 am on Monday, April 4, 2011

John Lennon had his own list of “what ifs”.  Pharmacy Chick has her own.  Over the last 2 and 1/2 decades in pharmacy practice, we have all seen huge fundamental changes in how health care is delivered and managed.  What used to be a physician/patient driven entity is now an insurance company driven one.

Patients understand this, but it doesn’t mean they “get it”.  The patient has a toddler’s mind when it comes to their health care. They refuse to think beyond the simplest of concepts.  they prefer black and white streams of thoughts and all they want is “what the doc ordered”.  Rarely do they think in terms of 1) cost, 2) necessity, or 3) availability.  I am a provider but I am also an “insured”.  I get the same paperwork each enrollment season that the clerk stocking the shelves does.  While I am more capable of understanding all the pages of literature they send out each fall, it doesn’t make it any more likely that I will sit and pour over every single page of it. I do however take some time to look at it each year to see what changes have been made.

Sadly, most people seem to live in a time where insurance meant ‘carte blanche’ with regards to health care.  Costs were low, and we didn’t have a lot of expensive stuff out there.  Insurance companies could pay their claims and still roll around in lots of cash.

I propose that one of our fundamental problems in the way we “run” health care is the insurance industry itself.  Think about it.  The Insurance industry is a FOR PROFIT org.  We make OUR money by delivering health care services and products to the patients who need them.  THEY make their money by delivering as LITTLE services and products as they possibly can, thereby preserving as much money for themselves/stockholders/dividends.  By denying services, they make money. 

I just want to know, Why is this a good thing?

WHAT IF, insurance was a not-for-profit org?  Where the money they brought in was 100% for services, products, and admin?   Why should insurance even BE a profit driven organization when profits are generated soley by denying or gate-keeping products from patients…and diverted to stockholders?

After all, they are merely a type of bank…premiums are paid to this “bank” who then pay them to providers when services are rendered….maybe..if its covered, if its filed properly, and if they feel like it.

Can we start a discussion?  WHAT IF INSURANCE WAS A NON PROFIT ENTITY>  What would change??


Comment by Froggy MC Frogerson

April 4, 2011 @ 11:24 am

Bash them all you want for the seemingly no boundaries on patients benefits but Medicaid programs have the lowest administrative cost, wish I had time to pull the reference but as I recall, Medicaid’s administrative cost is around 3-5 % while a commercial health plan is over 30%

Comment by BuckyPharmD

April 4, 2011 @ 12:51 pm

I’ve worked at a not-for-profit health care organization ( They operate within a small margin of profit, just enough to cover unforseen expenses. To keep costs low for members (who tend to whine when premiums get too high) they also have pretty strict coverage criteria. So even a not-for-profit or non-profit entity would still not be a place for members to get whatever services they want whenever they want. Regence policy provides coverage for services and medications when they have been shown to provide clinical benefit and are safe and effective relative to alternative treatment options. Not every drug and service out there is actually useful to patients.

What about we also take a look at industry here and stop providing them with incentives for developing me-too drugs and actually get them to be innovative? Maybe we could actually fix some of what ails us…

Comment by Ndemrose

April 4, 2011 @ 3:46 pm

How about they stop covering things like inhalers for smokers? This irks me to no end!!!

Or, be more preventative and cover preventive colonoscopies and mammograms regardless of the age rather than waiting until people are 50 and it’s too late so then they thrown into the “cancer” covering arena.

My guess is they could make some better decisions on coverage and spend less money. JMO.

Comment by PAS

April 4, 2011 @ 6:22 pm

What would change? Not as much as you’d think. A surprising number of things are not for profit. An absolutely huge chunk of things are self-insured, where the plan sponsor is full risk holder – usually a union/trust or employer that’s contracted an insurance company to operate the plan (Like Humana, or United or what have you). In such a scenario it doesn’t really profit to insurance company to deny a claim or no cover something – they don’t pay for it, and don’t keep the money that’s not spent. Indeed depending on the billing setup, thy can actually lose money if they’re contracted a payment on a per transaction basis.

Comment by Bluetowelboy

April 4, 2011 @ 7:34 pm

So if they don’t keep the money and if they don’t pay the claim where does it go? Money cannot be created or destroyed except by wallstreet so if money comes in for premiums and no claims are paid who gets to keep it. Ah that’s right the insurance company.

End of lesson. Someone benefits if claims are nor paid or if it is too difficult to file them. The insurance company gets to keep the money.

Comment by The Redheaded Pharmacist

April 4, 2011 @ 8:06 pm

Clearly the insurance industry has been granted a lot of power and control over the United States healthcare system. And they are making billions of dollars in the process. I think it is one of the drains on our system that results in Americans paying more for healthcare than other countries per capita. But, having said that there are bigger drains to the system as well. Fraud, waste, and abuse cost our healthcare system more money than the insurance companies could ever dream of taking in the form of profits. yet those factors seem to continually get worse every year as well.
If we are ever going to get a handle on healthcare costs in this country we have to look at all of the real sources of the extra costs and find ways to cut those down. I don’t see any politican or organization willing to take that honest look so things will continue on as is and even get worse going forward. But for the insurance industry healthcare is a perfect host to suck as much life out of because there will always be sick people who need care and treatment. They control all of the chips in this game and they know it! That is why they make billions and why you have to tell a customer you’ve helped for years that their insurance now is forcing them to use mail order. Ridiculous as it is it’s still our collective reality!

Comment by Jade

April 4, 2011 @ 8:27 pm

I like to think that ‘what if’ could start the first pebble of a landslide, by changing a mindset that healthcare is ‘for profit’. Some things should be run efficiently and judiciously, but health, at whose profit?

Comment by Linda

April 4, 2011 @ 11:18 pm

One of the most corrupt employers I had is a non-profit hospital system……..

They’ve paid multiple times for fines once “caught”. But, thos fines are figured in the “cost of doing business”

Disgusting. Non-profit is as bad as for profit health systems.

Comment by Erin, Tech

April 5, 2011 @ 7:15 am

I have had this exact thought for years, PC. I don’t understand how it is not a huge conflict of interest for insurance companies to be for-profit. Sometimes I have to explain to customers that it is the goal of the insurance company to make profits; not to facilitate their customer’s best interests.

Comment by K

April 5, 2011 @ 6:11 pm

My insurance has ridiculous copays for 90 day generic mail order fills, and they find the weirdest no-name “brands” you’ve never heard of. My not-for-profit protest is to fill any and all generic script that costs less or about the same locally. The thing that bothers me the most is not having all my scripts filled at the same pharmacy. There’s something comforting in knowing you have someone you know, and who knows you, watching out for you.I agree with ya kiddo. One of my personal issues is drugs that come from places I dont consider well monitored.

Comment by chris

April 6, 2011 @ 5:20 am

The only problem I see is that without profits, there would be no drive to form these companies in the first place. Sure a small minority of people do things out of the kindness of their hearts, but big business would not exist without profit. Profit is not the problem, regulation is, the insurance companies are allowed too much power and are allowed to do things that would be considered outrageous by normal society.

I also have a question regarding the not for profit healthcare? how far would you go, do you feel it should be just the insurance companies or all of healthcare, including medical practices and all the way down to pharmacies?

Comment by Pharmacy Mike

April 6, 2011 @ 6:19 am

Nationalized health care… like every other country in the world.

Health care costs less and performs better in just about every other industrialized country. Yet, we in the United States still wave the “we’re #1” banner.

The U.S. is like that asshole at a sporting event with the big #1 foam finger when his team is constantly losing. Last I check #37 is not #1. In fact, it’s nowhere near.

It won’t happen though for a number of reasons. One, everyone screams socialism. If a meteor were hitting the earth and the government wanted to fund a plan to stop it, half the country would say that the Constitution does not allow for meteor defense strategies.

Number 2, our politicians don’t actually work for the people. They work for themselves and for the GIANT CORPORATIONS they represent. Medco, United Health Care, Aetna, Cigna, CVS/Caremark, etc. are some of the largest corporations in the world. They would spend more than most of us would make in 100 lifetimes to stop any measure that would shrink their profits.

Number 3… People are stupid. Even if you showed them 100 studies that definitively prove something, they can shrug it off. “There’s no global warming. Sean Hannity and Rush Limbaugh say all those scientists are liars.”

It doesn’t matter though. I’ve given up hope on all humanity. I vow to use the health care system as little as possible. No physicals. No medication. No preventative tests. If I die at 35, then so be it. Who wants to be old anyway?

Comment by Loren Pechtel

August 22, 2011 @ 5:40 pm

It can be hard to keep up with the changes. You might get a reasonable listing of what’s changed–there’s no excuse for not reading that.

On the other hand you might just get a new set of rules with no indication of what’s changed. This is common when the situation got worse–it saves HR from some of the flak. Digging through it to figure out what has changed can be a royal pain.

RSS feed for comments on this post. TrackBack URI

Leave a comment

XHTML: You can use these tags: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>