My patient has had two heart attacks. You would think that his insurance company would try to prevent him from having another one. After all, you might say, heart attacks are expensive, and they wouldn't want to pay for that. You would be wrong on both counts.
Medicare does not pay for outpatient medications. This may have made sense when Medicare was created, since the cost and number of medications for the elderly were relatively low. However, nowadays, it's very tough to pay for the average senior citizen's medications. Hence, the Medicare Part B plans. These were put in place by the Bush Administration to encourage private companies to offer medication insurance for Medicare beneficiaries. Perhaps one problem with these plans is that they have less of an incentive to pay for prevention than traditional plans. After all, why pay for a medication to prevent a heart attack if you don't have to pay for the hospital stay or the bypass surgery? At least, that what I think is happening.
So, back to my patient. As overused as they may be for other indications, statins prevent heart attacks in patients who have already had one or more heart attacks. (Statins are cholesterol-lowering medications such as atorvastatin, a.k.a. Lipitor.) The American Heart Association and the American College of Cardiology recommend only the two most potent statins, atorvastatin and rosuvastatin, for these patients.
My patient had severe muscle aches on atorvastatin, and it barely touched his cholesterol. He tolerates rosuvastatin, and it is the more potent drug. There is no question that he should be on it. Yes, it's expensive, but he needs it, and it costs less than a bypass. Medicare Blue won't pay for it. I've appealed twice, and the second time, their letter basically said, "we'll cover this when hell freezes over."
Keep it classy, Blue Cross, Blue Shield.