The Vermont Political Observer
By John Walters

This won’t be news to any BlueCross BlueShield health insurance client, but the Blues did something this year that added fresh levels of annoyance to the lives of patients and providers throughout Vermont.

The Blues made a big change in its prescription drug coverage. It hired Optum RX as its pharmacy benefits manager. Which led to new, stricter requirements for a broad array of prescription medications. This will presumably save the Blues some money, but it will do so by offloading a lot of pain and extra work onto patients and prescribers.

(Before I go on, tip of the hat to fellow blogger Matt Sutkoski, who posted his own screed on this topic a few days ago. I’d been thinking about this for quite a while, but his essay crystallized my own thoughts.)

If you heard the ringing of a faint bell at the name “Optum,” that’s because it was a key player in then-governor Peter Shumlin’s Vermont Health Connect fiasco. Step with me into the Wayback Machine, which is set for October 31, 2014 — just a few days before the election Shumlin almost fumbled away to challenger Scott Milne.

On that day, we learned that the cost of VHC would be $20 million higher than expected. And that, my friends, was not the bad news. There were a number of horrible particulars, some of which involved Optum. Its employees were said to be poorly trained and making mistakes. A top VHC official observed that Optum had every motivation to let the work drag on and on, because the longer the project the more money it made.

So yeah, a corporation with some definite baggage in these parts.

What is Optum doing to, ahem, Optum-ize the Blues’ prescription drug coverage?

It’s substantially tightened the screws on coverage. I, like many other BCBS clients, received letters this spring notifying me of changes that would take effect on July 1. For some prescriptions, BCBS was asking my doctor to consider cheaper, generic drugs` whenever possible. For others, BCBS was forcing my doctor to get “prior authorization” — a specific OK from BCBS — before a prescription would be approved. I’ve been told by practitioners that this is an onerous bureaucratic process that adds time and paperwork for what ought to be routine approvals.

This requirement includes medications I’d been taking for years. One example: I have diabetes. I’ve been taking a couple of low-cost medications for quite some time. Last year, my doc added a newfangled costly drug to the mix, and it has made a huge difference in managing my condition. It’s brought down my blood sugar and helped me lose weight.

This spring, my doctor was asked to stop the miracle drug and substitute generics.

Generics which I was already taking in addition to the new drug. Yeah, I need all three.

My understanding is that Optum is imposing universal guidelines, probably by way of a computer algorithm, onto every patient’s regimen. This results in nonsense like my diabetes recommendation. It’s absurd on its face. Any doctor, nurse or pharmacist would tell you that. But my doctor and I are forced to jump through hoops to get authorization for a drug I’d already been taking and I clearly need.

It’s a minor annoyance, but now multiply it by the number of BCBS clients who take prescription medications. Every provider’s office in the state had to deal with thousands of these demands from BCBS. I got four of them myself.

It’s only fair to acknowledge that BCBS is stuck between a rock and a greedy pharmaceutical industry. The cost of prescription drugs is a major driver in the skyrocketing cost of health care coverage. The Blues can’t impose sensible reforms on Big Pharma’s business model, so it has to squeeze out savings wherever it can to try to hold down the cost of insurance. So they’re hiring a company with a checkered past to apply the blunt instrument of algorithm-based limits on coverage.

It’s just one more reason why we need single-payer health care.