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its-not-fair

From the time my number 2 son could speak he shared with us all the ways in which he was not being treated fairly. His lower lip would quiver, his breathing would become labored and then, the magic words would come out: “It’s Not Fair”. Whether it was because his older brother had sent him away after he had become annoying or it was because another sibling’s piece of pie was larger, the mantra continued for years.

I remember as a rookie sales rep complaining about something and the “crusty crabs” in the office told me that life was not fair, that fair was just another four letter word. Somehow they felt that fairness and business were not mutually inclusive.

When my child left for Vet school two years ago I picked up his three magic words because they explain so clearly when things are just not right. Yet our challenge is to not only identify unfairness, but also to address it.

How is it fair that an individual who has had prescriptions covered on a health plan suddenly is notified that things have changed mid-year? Either the copay has changed or the drug has been taken off the approved list. There are now drugs that cost well above the average American family’s means, but which are vitally necessary for the care of individuals in those families. The rules of enrollment now prevent plan changes mid-year although the basic healthcare needs of the insured may no longer be met by the current plan.

There is a question in many of our minds about the cost of drugs: are prescription prices based on what the market will bear or do those prices have some relevance to the actual cost of the drug? Many of us wonder why drugs that are not particularly expensive and have always been covered are suddenly not part of the approved list for our plans.

We scamper to help our clients piece together drug discount programs and enrollment in special pharmaceutical programs when prescriptions are suddenly not covered. We help appeal to insurance carriers as specific prescriptions are replaced by lower cost options when these alternatives have proven not to be effective for the patient. We try to level the fairness playing field as much as we can, but our ability to impact positive decisions is reduced each year.

There was a time in the health insurance industry when insurance companies worked with physicians to help patients meet legitimate needs if they fell outside the parameters of the insurance contracts. It was a less expensive time and drug prices had not hit the often inexplicable highs they have recently. It was also a time of cooperation and accommodation, features long lost in the health insurance industry.

Is it possible to make things fair again? I am not sure, but for the time being I will simply point out when things are not fair and continue to see the world from a child’s perspective. If fair is just another four letter word I would like it to join its rhyming partner “CARE” and introduce them both to the decision makers in the health insurance industry, particularly those who determine our prescription benefits.