Red Tape

Hello from the hospital. Yep, we’re still here, despite getting the doctor’s okay to go home two days ago. We are still here because insurance company employees don’t work on the weekend.

Gracie has had many, many courses of antibiotics in her short life. She has had more types of antibiotics than I can probably name here, although I’m going to try anyway: Augmentin, Amoxicillin, Bactrim, Cefalexin/Keflex, Cefdinir, Cefepime, Ceftriaxone, Clindamycin, Daptomycin, Levofloxacin/Levaquin, Linezolid/Zyvox, and Vancomycin. I may have forgotten some; the point is, she has had a LOT of antibiotics. Most have been for Staphylococcus aureus (staph) infections of the fingers. In the summer before she turned 2, she probably had ten courses of antibiotics for cellulitis infections in her fingertips, culminating in her first long hospital stay for gangrene and osteomyelitis and a subsequent 5-month course of Clindamycin and Levaquin.

Antibiotics are similar to other drugs, in that the more you take, the less effective they are. She has had so many courses of Keflex and Clindamycin, for example, that neither helps her much anymore, at least not for staph infections. She is allergic to Bactrim, a more heavy-duty drug that treats staph infections, so that’s off the list of possible treatment options (she got a skin rash from that drug, erythema multiforme, and it can be very serious, even leading to blindness in some cases, so we’re not willing to try that again). She’s also allergic to Vancomycin, one of the big-gun drugs to treat staph—she gets a reaction called Red Man Syndrome, which makes her really itchy and makes her head turn red. Even trying to ward off the reaction with Benadryl doesn’t help; she is miserable with Vanco. The weird thing is that Vanco doesn’t really seem to help her, anyway—when we’ve given it to her in the past, it hasn’t changed the course of her infections. So, she is left with one option for treating staph infections: Zyvox, or linezolid.

Linezolid (lihn-AY-zoh-lid) is very expensive. One time, we couldn’t get insurance approval for whatever reason, and the pharmacist told me the prescription would be $3,499 out of pocket for a two or three week supply. Um, no—not able to front that cost! We had to jump through several hoops that time, but we eventually got the insurance to pay for the medicine.

So, speaking of hoops, back to why we’re still here. On Saturday, the hospital’s new infectious disease doctor said that he would be fine with discharging her on oral linezolid. He asked if the insurance would pay for the med, and I said they always have in the past, but they require pre-authorization and the pharmacy needs 24 hours to fill the prescription because they don’t keep it in stock. He spoke with the hospital’s case management team, and they contacted Anthem, Gracie’s primary insurer, to start the authorization process.

I found out later that day that they could not get pre-authorization for linezolid because Anthem was closed. We would have to wait until Monday, when the business office opened again. Today is Monday, and presumably everyone’s back to work, but we still haven’t gotten the authorization for Gracie’s expensive medicine.

It is incredibly frustrating that the insurance company is keeping us here. Apparently the good folks at Anthem would prefer to pay $15,000 for a hospital stay instead of simply approving the medicine that they’re going to have to approve anyway. Even though there are several legal proscriptions against insurance companies practicing medicine, that is effectively what’s happening here. The insurance company is dictating Gracie’s treatment because they are preventing her from receiving the medicine she needs.

There are two sides to every coin, and I am trying hard to understand the insurance company’s reasoning in requiring pre-authorization for this medicine. It is VERY expensive; to contrast, a run-of-the-mill antibiotic like Augmentin costs approximately $18 without insurance. Clindamycin, which is also one of the higher-end antibiotics, costs about $90 per bottle without insurance. Linezolid costs about $1,200 per bottle. I can understand that the insurance company would want to discourage doctors from prescribing this very expensive medicine.

However, most doctors are reluctant to prescribe antibiotics at all unless necessary. Most prefer the course of least intervention, and follow the axiom that it’s best to do the least-interventive measure first, because if that doesn’t work there is something else to try. Most doctors would not prescribe linezolid to anyone who didn’t need it.

Gracie absolutely needs it. She has had so many infections and so many courses of antibiotics that she (0r rather, her staph bugs) are resistant to everything except the big-guns. We try very hard to keep her off antibiotics; I treat everything I can at home without medicine, but there are times that the infection turns a corner, like it did this time, or gets drastically worse, like has happened so many times in the past, and antibiotics are our only option. We try our best to stay out of the hospital, but it doesn’t always work (as evidenced by the fact that this is her 11th hospital stay, all for types of infections). Hospital stays are our last resort, our final intervention.

This hospital stay has been unnecessarily long, all because of insurance red tape. It is incredibly irritating and frustrating to know that we are only here because no one at Anthem was working this weekend. We are only here because Anthem would rather pay for extra days of hospital costs for Gracie—and who knows how many other people—than pay for one employee to be on call or at work on the weekends. We are only here because Anthem is dictating Gracie’s medical treatment by denying her physicians the opportunity to make intelligent and reasoned decisions about which antibiotic she needs.

We are only here because of red tape. But GAWD, that red tape is hard to get through!

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