A life with lice
I was working in an urgent care and a patient I had previously seen for lice came in with the complaint of body itching.
A rapid recurrence signaled we were dealing with more than just a case of lice.
The disheveled man was covered in sores and excoriations, with small insects flopping around his soiled clothing. He had moved back into a shelter, and despite being seen by a doctor recently with the correct treatment prescribed, he had not been able to acquire the cream. He presented to the pharmacy but was told the medicine was $20 (the out-of-pocket cost), which he wouldn’t have until his next social security check arrived. Looking for an alternative to further delays in treatment, I quickly viewed his insurance information on the computer and recognized he was covered by both Medicare and Medicaid. Medicaid should have covered the cost of his medicine completely, even if Medicare didn’t. I suspected that the pharmacy did not have a copy of his Medicaid card indicating prescription drug coverage. I asked him to pull out his insurance card from his wallet. He showed me his Medicare card, confirming my suspicion. I then advised him to present the Medicaid card (also in his wallet) when he went to pick up his prescription instead and had him repeat the instructions back to me. Poor understanding of how to navigate the health system and insurance, and likely a number of other barriers led to delays in treatment and an unnecessary visit. He left hopeful he would sleep better after treatment. Sadly, he was not the first homeless patient I had seen lack the ability to pay for lice treatment and he would likely acquire lice again in his cycle of homelessness.
Treating the patient is more than prescribing the right medicine. It is prescribing the right treatment to the patient-in-environment. The key to getting his medicine paid for was in his wallet the whole time! What systemic solutions could we consider to avoid similar delays in obtaining prescriptions? Here are a few ideas:
When treatment doesn’t go as planned, ask about navigational errors, environmental and physical barriers, not just health knowledge or attitudinal barriers
Development of single insurance chipped electronic cards which can link all of a patient’s insurance coverages together
Linkage of insurance beneficiary rosters to contracted pharmacy databases (particularly for Medicaid patients) at the time of fill (obviating a need for a card)
Prompts on pharmacy computer systems to ask for other forms of insurance or payment to use before patients walk away from the counter empty-handed
Automatic message generation from the pharmacy to the prescriber when a prescription is filled but not picked up, with a drop down reason list such as “not covered,” “high out-of-pocket cost,” “side effects,” etc.
Automatic text or phone message generation from prescribing offices to patients with new prescriptions to ask if they successfully received their prescription and are taking it. If the option if “N” is texted back, it could give an option list as to the reason and then send a message to the prescriber’s team for follow-up.
Perhaps some of these ideas seem futuristic, but we must start! From the patient perspective, it can be hard to imagine solutions that don’t exist. However, the patient’s story often contains the most important clues as to what types of solutions are needed.
