With the West Marin Medical Center in Point Reyes Station about to stop caring for thousands of patients, Zsuzsanna Biran, pharmacist at Point Reyes Station’s West Marin Pharmacy, has sent this blog a description of how health-insurance companies are sabotaging health care.

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Zsuzsanna Biran (above) and Jason Yoon bought West Marin Pharmacy last year after previous owner Dan Donovan died unexpectedly. The pharmacy has been hard pressed both by the inadequate payments from health-insurance plans and by Medicare’s refusal to reimburse her for prescriptions filled until she gets her own Medicare certification for the drugstore. She belatedly discovered she could not take over the certification the pharmacy had under Donovan.

Meanwhile, West Marin Medical Center will close at the end of December, Dr. Molly Bourne has announced, and this will leave 4,000 patients without their primary doctors.
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portraitsmall.jpgDr. Bourne (seen at right in a picture from her website) told The Marin Independent Journal last September that problems with health-insurance companies are forcing her to close the 53-year-old clinic. “The practice of medicine has changed from medical care to managed care,” Dr. Bourne explained to The Independent Journal, “and I don’t like being told by an insurance company what drugs to prescribe or what protocols to follow.

“The insurance companies pick and choose what they’ll pay for, and it’s not enough to be able to sustain my practice. I’ve bounced a lot of checks in the last year because I haven’t been able to pay myself. Reimbursement from insurance companies requires to much paperwork that three of the center’s four employees work fulltime at processing forms and documents.”

Independent Journal reporter Rob Rogers noted, “The insurance companies often do not reimburse the clinic for the cost of the treatment for several months, making it difficult to cover expenses.” In addition, Rogers quoted Dr. Bourne as noting she sometimes has to “eat” the cost of providing medical care to patients whose health insurance company refuses to pay for it.

Here is how pharmacist Biran describes the situation:

The Insurance Myth….

Once upon a time in the good ol’ days, when you got sick, you went to the doctor and paid your bill and then went to the pharmacy to fill your prescription. You could expect to pay a reasonable amount and still have some money left over to get yourself a decent dinner. The pharmacist and the doctor could also buy decent dinners for themselves, and everyone lived happily ever after you finished taking your medicine and got well.

Now jump to the present when that all this has been updated by insurance. You go to your doctor, who bills the insurance for your visit and charges you a co-payment. The insurance payment won’t come in for a while, and when it does, it will pay 40 cents on the dollar. So dinner has to wait… which is why none of the doctors you see in Point Reyes Station have a weight problem.

100_5883.jpgAnd the pharmacy? An even worse scenario. Just as you have to sign up with the insurance company, I have to sign up with each company I deal with… and sign a ‘take-it-or-leave-it’ policy, which doesn’t leave any room for negotiations. And I have to pay for the privilege of belonging to their programs… and pay a software company each time I bill a claim.

The insurance only takes into account an assigned (by the insurance) cost for the drug, so no overhead expenses get included in the payment. What mostly happens is that the only payment I ever see, especially on a generic prescription, is the discounted price, the insurance company mandates. So when you pay $1.34 or in some cases $5 or $10 for a prescription, [your “co-payment”] is ALL I get. The insurance company does not pay me any more.

I’ve now started to “come out of my shell” and let people know that nobody is making up the difference between what a medication’s going market value is [for uninsured patients] and the discounted rate I actually get.

If a medication is expensive, insurance companies often refuse to cover it. If they do, they make you pay for the medication at an assigned ”discounted” rate. For example, if the discounted rate is $145, no one is making up the difference between that and what a patient without insurance would pay the pharmacy.

I have chosen to speak out because of what happened with Dr. Molly Bourne. It occurred to me that the community deserves to know what is going on behind the scenes. From speaking with many of you at the pharmacy, it is evident that most people with health insurance are under the impression that the insurance companies pick up at least part of the tab most of the time. This is no longer true. Au contraire; it’s almost the opposite.

I know I am leaving you with a cliff-hanger, but as I write, I still don’t know the end and where it will lead, what road we’ll go down on. I do believe we are all responsible for our destinies. In spite of all of the above adversities, I am enjoying being part of this community, and it is a pleasure and a privilege serving you, living and working here. I thank you all.