Tom Sengupta, a pharmacist in southeast Minneapolis, says that he has never denied a customer a drug if the need is legitimate. During the 37 years that he has operated Schneider Drugs on University Avenue, he has filled more than 1.2 million prescriptions. “If I’ve known someone for 30 years,” Sengupta says, “I’m not going to deny him his drug because his insurance company will not authorize that drug.”
As an independent pharmacist, he quickly points out that he does more than filling prescriptions. He also advises patients on the selection, dosages, interactions, and side effects of medications, and he deals with drug companies and insurance companies.
Sengupta knows all his customers, and he cheerfully greets each one by name. He consults with each patient in the store as he monitors their health and progress to ensure the safe and effective use of medication. He also dispenses advice over the phone. In many instances, it is easier for a patient to reach Sengupta than to reach a doctor.
Despite Sengupta’s good nature, he complains of his increasing frustration with insurance companies. Drug pricing, reimbursement, authorization, billing, and reimbursement procedures present challenges for him almost daily, which “takes its toll and creates a wall” between him and his patients, he explains.
About 85 to 90 percent of the prescriptions he fills are covered by insurance, estimates Sengupta, with the remaining paid by individuals. For each prescription covered by insurance, Sengupta first requests authorization from the insurance company to fill the prescription. Receipt of authorization also serves as the approval for reimbursement of the amount Sengupta paid for the drug.
Sengupta has to contact the appropriate insurance company, which varies for each prescription. For patients with Medicare Part D, for example, Sengupta contacts up to 63 different insurance companies, and each insurance company has its own rigorous standards and procedures. He does bookkeeping, he says, for over 200 insurance companies. Sengupta says he he sometimes feels like he is their customer service clerk
Each company’s standards change periodically, most often at the beginning of the year. For example, a drug that was covered one month may not be covered the next. The pharmacist is thus placed in the position of explaining the situation to the patient—and, in some cases, to actually advocate on the patient’s behalf for authorization and payment.
More than half of authorizations requested are approved within a few minutes. For others, the entire process can take more than thirty minutes. The reason could be simply that the patient was unaware that their coverage had changed, or that their employer changed insurance providers, or that the patient’s new insurance card was misplaced. Whatever the reason, Sengupta has to help the patient understand the process.
Sengupta’s frustration flares highest when a insurance company denies authorization.
“Patients don’t know what’s going on,” he says. “Sometimes a drug will be approved for a while, then suddenly it’s not approved.”
The patient is faced with a decision as to whether to forego the drug or pay for it out of his or her own pocket. If the patient cannot afford the drug, Sengupta will suggest that the patient ask his or her doctor for an alternative drug that is less costly, or Sengupta himself will give the customer a discount. In many cases, the high cost of the drug is prohibitive. Sengupta asks, “What kind of society do we want? Do we fill our prescriptions or pay heating bills?”
Sengupta believes that the entire health care system needs to be overhauled. “A single payer system would eliminate the frustration of dealing with so many drug companies. It would save my time and my customers’ time.”
“Prescription costs are too high,” says the pharmacist. “We have to take a look at how much profit is too much. Look at how much is spent on research and how much on university. What do we want to leave behind for our kids and grandkids? Health care is a privilege; it should be a right.”
Jennifer Holder (firstname.lastname@example.org) contributes regularly to the TC Daily Planet and the Minnesota Spokesman-Recorder.