On Wednesday, economist/domestic policy expert and Washington Post columnist Ezra Klein sprang a big one on readers: The health insurance industry is hell-bent on making money, first and last.

Michael Moore broadcast this fact in Sicko two years ago, but hey, it's a new presidential administration, a new media angle. Health care reform is now all the rage. Big Insurance and its sister Big Pharma have been belatedly identified as the bad guys, and not just by raging liberals.

Not that they were the only ones to agree with this truth when the film first came out - I remember seniors coming to the pharmacy where I used to work, gaping at their drug costs, finding out they were in the doughnut hole (better understood as the drug cost "coverage gap" in which the patient is responsible for 100% of the cost of their medicine until the "catastrophic" level - typically $2000-3000 - is reached), and sinking into a confused, anxious haze while I or the pharmacist did our best to explain this surprise loophole. A few times I let slip the tip that Sicko was playing down the street at the Showplace 8, gave them a brief overview of the film's content, and was not surprised when they asked about show times. I don't know why I felt the need to be covert when I mentioned the movie to these patients - I would lower my voice, make sure the pharmacist/other techs weren't watching or listening, etc. - it must have been my instinct as someone on the far side of the health industry "counter," as it were.

Only later would I realize that most pharmacists are just as bitter about the Medicare Part D boondoggle - and for-profit insurance in general - as are so many patients. It comes of being at the person-to-person level of care, on the front lines miles away from administrative/legislative HQ, I suppose. One of the first things people see fit to tell me when I say I'm a pharmacy tech is that they've had some run-in or other with a rude pharmacist who "refused to give me my pills," and this does happen quite often, and there are a lot of cranky pharmacists out there (the reasons for which could fill another whole blog entirely - let me just say I would never want their job!) - but almost always the "refusal" is not on the pharmacist's order, but on that of the patient's insurance provider. Some grouchy pharmacists, it's true, have built up an abhorrence of the public over the years, a thick skin and preemptively temperamental tone after passing along this unpleasant news too many times to count. But when you get down to it, it isn't their fault. The insurance companies are covering their butts (i.e., minimizing "medical losses," as noted by Moore and Ezra Klein) by adhering to rigorous days' supply requirements, sometimes dubious drug formularies, "step-therapies," limits on retail pharmacy rx fills, etc., etc.

A run-down of the claim-rejects in the above partial list:

Days' supply: Most prescription insurances will cover only a 30- or 90-days' supply of medications, a regulation which many of you have no doubt encountered when you've made a pharmacy stop expecting to have your rx ready and waiting. This is annoying, yes, especially if you're about to leave the country for a month. But it's the most basic way to control costs, both the insurance providers' and the pharmacy's. An added plus is the prevention of medicine stockpiling, important for drug abusers and the doctors they harass for endless refills. It's also something that would definitely be included in any government plan, sorry to say, especially one that hopes to be as cost-conscious as Obama's.

Drug formularies: This regulation can often seem less reasonable, and oftentimes it really is. It's also a point at which Big Pharma and Big Insurance are usually at vicious odds. (Contrary to popular belief, despite their shared fiduciary interest in profiting off sick people, the industries are engaged in an epic battle: Pharma wants to sell lots of drugs, Insurance wants to pay as little as possible for them. In this situation, pharmacies and doctors are the beleaguered referees, more so the pharmacies since doctors aren't always up to speed on their patients' insurance limitations. Which can be a huge pain in the ass for us pharm folk.) Formularies are lists of drugs that insurance providers agree to cover, in whole (almost never) or in part (to widely varying degrees). When your doctor prescribes a drug that is not on your insurance's formulary (lots of new drugs fall into this category), they won't pay, or they'll contribute a miniscule amount that translates to "Bad patient! Tell your doctor to prescribe something cheaper!" The latter happens most often when a brand has become available in generic form. Insurance companies are always on top of the latest patent expirations. Formularies will exist under a government plan, but it's hoped that the plan will pay more attention to drug efficacy than cost when determining which drugs to include.

Step therapies: Has your doctor ever prescribed a new drug that your insurance won't cover because they want you to try something(s) else first? Very common with antidepressants, this obstacle to prescribed treatment may postpone your doctor's and your desired results. In this case, your insurance wants to pay for a cheaper drug before they'll give in and dole it out for what your MD deemed best for you in the first place. Sometimes the substituted drug works well enough and money is saved, but it can be galling to tough out the inferior treatment when it doesn't. Probably this won't disappear with a government plan, but again, hopefully efficacy will have greater weight. After all, despite heavy industry marketing of certain brand-name drugs (see Seroquel, Seroquel Part II), they aren't always any better or have fewer side-effects than older ones.

Limits on retail pharmacy fills: Some insurance companies have deals with pharmaceutical distributors that require patients to "go to mail-order" after a set number of rx fills at a retail pharmacy, usually 2 or 3. In my experience this has been most common among seniors' Medicare Advantage plans and some employer-provided insurances, to sometimes detrimental effect - snail mail is so reliable, after all. I've encountered many instances of patients being forced to pay cash for a guesstimated number of pills to tide them over until their covered prescription would (hopefully) arrive in the mail.

Again, this is just a partial list. Probably on Monday when I go back to work, we pharmacy techs and pharmacists will run into common claim-rejects that I couldn't call to mind for this post, and I'll think, Dammit, that was a good one. I didn't even touch the dreaded Prior Authorization!

So, yeah. We in the pharmacy business may sometimes be cranky, but it's just because we care! Or something. Seriously, though, insurance is just about as confounding for us as it is for you. Not only are we negotiators, but we have our own health insurance, too. We just get paid to go to bat for you guys as well. Or at least try.