“Insurance = Evil”? Think Again.

Hi all! My name is Tony Lin and I will be a P3 in September. I apologize for those that have been dying to hear how “brain-washed” I am with my Managed Care (aka insurance company) internship…it’s better being late than never!

This summer I will be interning at Blue Cross Blue Shield of Michigan (BCBSM) Department of Pharmacy Services.

Perhaps for those that have worked in community pharmacy (or from your own personal experience), many people often view the insurance companies as these evil groups that never seem to pay for any drugs for the patients. To tell you that any “Prior Authorization” or “Rejection” messages are being displayed on your pharmacy computer screen only after complex logical calculations might be hard for you to believe. Well, the analogy I would use here is that many people think all pharmacists ever do is count pills—try again…it IS more complicated than just that!

In a nutshell, an insurance company (aka a Health Plan) pools financial resources together from clients (such as your parents’ employers) and use them effectively in paying for the claims (prescription drugs in our case) filed by beneficiaries. With limited resources, strategies must be implemented to be cost-effective.

While most of the public think that drugs are like cars—the newer the better, us pharmacists know better and realize that it is not always the case. Many drugs can easily cost hundreds or thousands of dollars per prescription or per unit. This is why insurance companies set Prior Authorization in place, ensuring generic drugs (which work just as well as brand names) or other more inexpensive alternatives have been tried first.

My specific duties this summer are to be with the Pharmacy Network team. The team prepares, reviews and manages all contracts from pharmacies in the state of Michigan. No—Blue Cross isn’t the DEFULT insurance for anyone. And yes—each individual pharmacy (chain or independent) must set up specific contract with BCBSM in order to serve patients with Blue Cross plans. More on this will come as the summer goes on.

I’m going to leave you all with few “Blue” Fast Facts:

** Total Employees: 7000 (3000 employees just moved their offices to downtown Detroit from Southfield to join the existing 3000 employees that were already in the city)

** Members: 4.3 million

** Claims paid in 2009: $19.8 billion ($5 billion paid in pharmacy claims)

** 50 million pharmacy claims annually

Did you know?

** Nearly 92 cents from every dollar BCBSM collects in premiums goes to pay for health care services.

** Of the nearly 30,000 doctors in Michigan, more than 99 percent participate with the Michigan Blues.

** Nearly 2,400 pharmacies in Michigan participate with Blues plan prescription drug coverage programs.

** There are 159 hospitals in Michigan. They all participate with the Michigan Blues and accept the Blues member ID card for health care coverage.