Jim Plagakis, RPh
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"Doctor, you are going to have to call your insurance company for a prior authorization if you want them to pay for this."
I was educating a young physician in a disturbing feature of the medical professions. Dressed in well-used green scrubs, he
had a thin beard and wore a heavy beaded necklace like the one Josh Beckett, the Red Sox pitcher, wears. He looked tired,
as residents tend to look. He had called in an Rx for Protonix for himself.
"What does that mean?" He had a why-are-you-bothering-me-about-this? look on his face. "Why can't you just fill the prescription?"
"We can just fill it, if you want to pay full price." I gave him my most winning grin. I had learned that physicians are the greediest
when expecting their insurance to shell out. I went on. "If you want your insurance to participate in the payment, you will
have to get a PA." I shrugged. "That is just the way it is, man."
He let out a big sigh. His shoulders drooped. He was a tired puppy. I could tell that he was now ready to let the pharmacist
play the dance music. He would willingly move his feet to my lead. "What do I have to do?" I explained what a PA is. "You are the patient and you are the doctor, so you are up to bat. We cannot do this for you, but
it should not be a problem." I asked the technician for the PA telephone number, dialed it, and then handed the phone to the
young man. "Since you are the patient as well as the prescriber, they may give you trouble. Just be assertive. You will get
what you want."
I went back to work, but I kept my eye on him. He was doing a lot of talking, but he was not raising his voice. It was a good
half hour before he handed the phone back to the technician and went to sit in the waiting area.
It was an instructional moment that I could not pass up. I went and sat beside him.
"That is a small taste of the indignities you are going to have to put up with if you go into a fee-for-service practice."
"What's fee-for-service?"
"Private practice. You charge a fee for every medical service you provide. The insurance companies then discount it by 40
percent and you take the money and you do not complain."
"I'm not stupid," he said, I'll be an employee and get a regular paycheck. Maybe Kaiser Permanente." He smiled. "That discounting
of fees is bullshit."
"It's our own fault," I said. "You, me, and the rest of the medical professionals have allowed the insurance companies to
bully us. We are like the skinny sophomore that gets stuffed into a locker by the big boys." I recalled the memorable and
bloody scene in the movie "A History of Violence" when the bully had his clock cleaned by the sophomore. I'd love to feel
the satisfaction of seeing the insurance bullies bloodied up a bit.
He looked at me. I was older, wiser, and more experienced. "What can we do?"
"One of these days," I said, "doctors, dentists, the major drugstore companies — they will all take the dignified position
of simply saying, No More. We will bill $100 and that is what they will pay."
When I took his prescription of pantoprazole to the register, he asked me where the Zantac was. "I need some rapid relief.
I am a surgery resident. About ten o'clock this morning, the sonuvabitch just walked away from a heart-valve repair and told
me to finish it."
"What was that like?"
"It was like a Niagara of acid. Immediate."
We found the store brand of Zantac. This kid was a physician. He had been thoroughly trained to stand tall at the top of the
medical pyramid, but he was not close to knowing what pharmacists know. I said, "I noticed that you put a bottle of Pepto-Bismol
on the counter. What's that for?"
"That's for PRN use. When I need something right now."
"Bad choice." I told him about magnesium hydroxide and put a box of three rolls of Rolaids in his hand.
"Are you serious?"
"Try it right now."
He did. He chased three Rolaids with a chug of Dasani. His eyes widened. He smiled. Then he said, "You're right."
JIM PLAGAKIS is a community pharmacist in Galveston, Texas. You can e-mail him at jpgakis@hotmail.com
and cc us at drugtopics@advanstar.com
. You can also check out his website at http://jimplagakis.com/.
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