I found this in the comments over at Corrente and wanted to share it:

Insurance companies reserve the right to make changes to their formularies at any time, but are supposed to notify you and allow you one month's supply of your current drug in order to give your medical provider the opportunity to "pre-authorize" your access to said drug. Your doctor cannot simply write a letter saying "I'm the doctor by god, and I want the patient to have this drug". No, he must provide evidence that he has "stepped" you. Stepped means that he/she has tried you on "approved" A, B and C drugs to little or bad results first.

Now, A and C may no longer be on the formulary, so they don't count, so he/she has to find out what approved drugs are on the formulary so that he/she can say that they have been tried and if that is true, or he/she will say it is true, then it will go to the Pre-Authorization department.

If the PA department can't sort it, say because your diagnosis does not fit neatly into what the insurance company says the drug can be used for, albeit that it works for what ails you, the application goes to the in-house pharmacist. The in-house pharmacist (average salary $90,000 per annum) will make the final decision based on following company guidelines and keeping his/her job. If the decision is that you get the drug, then said drug will be approved for you as "off formulary", moved to class 3 and if your co-pay was $25.00, it will now be $60.00 or more.

If the drug is not approved, then you will be properly stepped with the ineffective, approved drugs before your pre-authorization can be reconsidered. After you have been stepped, the drug will still be off formulary and the co-pay will still be increased. It sucks and I am so sorry.

Signed Anguished in the PA Department - United Health Insurance Inc

(Disclosure: I'm working with Brave New Films on their Sick For Profit campaign, exposing insurance industry practices. Check us out on Facebook.)

The New York Times published a very nice press release from the desk of Humana, one of the nation's largest health insurance companies. The reporter interviewed a bunch of employees at Humana, all of whom were horrified to see themselves depicted as "villains" in the health care debate. I agree with Yves Smith, this is an absurd angle for a story, an extreme example of selection bias. The people who work at Humana probably have a sense that their employer, um, pays their salary, and thusly, what's good for the employer is probably good for them. Similarly, most people hold a favorable opinion of themselves just as a matter of getting through the day. Not to mention the fact that their understanding of the functioning of Humana is limited to their job description. It is not possible to gain much of a perspective on the health care debate or industry practices by asking a midlevel manager "Do you think you're the worst person alive?"

Since when is it legitimate, much the less newsworthy, to get a company's perception on its embattled status, at least without introducing either some contrary opinion or better yet, facts, to counter the views of people who will inevitably see what they are doing as right? I hate to draw an extreme comparison to make the point, but staff in Nazi concentration camps also thought they were good people. It is well documented that for all save the depressed, people's assessments of their own behavior is biased in their favor.

There is some revelatory stuff in the article, however. David Sirota flags one employee saying that Humana believes in keeping down costs by "controlling utilization":

Now, I know we're supposed to think that private for-profit health care companies don't ration care, while government-run programs like Medicare do - but as the insurance industry admits right here for all to see, that's just not the case. The obvious truth is that the health insurance industry works hard to "control utilization" - that is, it works hard to make sure that when you need a costly medical service, you are "controlled" (read: prevented) from getting it.

Sure, we're all against excessive testing - and there are good ways to deal with those inefficiencies. But that's not what the insurance industry is talking about. It is talking about its practice of rationing care - and now that reality is right there in black and white for all to see.

The truth of the matter is that many of the charges that insurance companies like WellPoint level at the public option and regulatory changes sought in the health reform bill mirror accepted industry practices. WellPoint, which emailed its own customers yesterday attacking the Democratic plan, claimed that health reform will “increase the premiums of those with private coverage.” Yet WellPoint routinely hikes their own premium prices by close to double digits annually, leading to ever-increasing profits. The email stated that millions of Americans would lose their private coverage and be forced onto a government-run option if the Democratic bill passed (nothing could be further from the truth); yet WellPoint routinely uses the practice of rescission to drop their own customers from coverage if they ever try to use it, and they've admitted they would continue doing so unless forced to stop by law.

The email is an example of the astroturf practices from the industry, including, no doubt, pitching to the New York Times a story putting the human face on insurers. Many of these astroturf efforts spring from the same sources as the corporate lobby groups activating the tea party protests at town hall meetings throughout the country this August. They're trying to change the subject, away from facts, like how they're spending less of their premium revenue on medical care over the years, from 90% in the early 1990s to around 80% today. Or how they use rescission and pre-existing condition to make profits off cherry-picking the healthy and denying everyone else care. House and Senate leaders have requested more and more information about insurance company practices; Dennis Kucinich has joined that effort. But the insurance industry, while nominally siding with reform, wants to keep the focus on efforts against it, in service to de-fanging it.

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There's no shortage of wingnuts out there, so why would George Stephanopoulos invite on someone too crazy for even Bill O'Reilly? Only people with a Malkin brain would believe and push across the notion that Americans would rather collect three hundred dollars a week on unemployment insurance rather than get a job that supplies benefits and pays a salary.

Yea, because there are so many jobs available, people will just wait until the insurance ends and then immediately get hired. I'm sorry, where are all these jobs again? On ABC's THIS WEEK Malkin made this bogus claim. A quick Google search uncovers that when Michelle claims Larry Katz once said that the benefits could discourage people from seeking employment, Katz actually said just the opposite during our current financial mess:

Traditionally, many economists have been leery of prolonged unemployment benefits because they can reduce the incentive to seek work. But that should not be a concern now because jobs remain so scarce, said Lawrence Katz, a labor economist at Harvard.

For every job that becomes available, about six people are looking, Dr. Katz said. “Unemployment insurance gives income to families who are really suffering and can’t find work even if they are hustling to look,” he said. With the economy still listing, he added, a temporary extension can provide a quick fiscal stimulus. And, Dr. Katz said, when people exhaust unemployment and health insurance, many end up applying for disability benefits, which become a large, unending drain on the Treasury.

It does help to fact check what conservatives say.

Malkin: If you put enough government cheese in front of people they are just going to keep eating it and you're just kicking the can down the road and just to hammer this point about the unemployment benefits extension again it was Larry Katz, who's a chief labor economist under the Clinton labor department who came out with a study and there are a lot of these economists who say this that if you keep extending these "temporary" unemployment benefits you're just going to extend joblessness even more.

Stephanopoulos: I don't know if I follow that though

Malkin: That was a Clinton economist who said it George...

Stephanopoulos: Choosing to take the unemployment benefits when a job is available?

Malkin: Seventy nine weeks already and then they're going to extend it by another thirteen weeks and what happens is according to these economist who have seen it including this Clinton economist is that people will just delay getting a job until the three weeks before the benefits run out.

Tucker: Well, that might be true when there are jobs out there that are available, but there are very few jobs available at the moment so I don't think people are using that unemployment benefit to be lazy instead of going out and searching for jobs...

Malkin: I'm not making a moral judgment, it's an incentive problem.

Tucker: But when businesses advertise the few job openings they have, they'll advertise twenty openings, they have six thousand applicants so I don't think that's the problem...

Hunt: If Starbucks were hiring, suddenly you'll see lines around the block. Anecdotally George, I have a kid who has some friends from college and many of them don't have jobs and boy, they are looking.

Stephanopoulos: And there are other states especially that are hard hit.

I know she probably worked on her government cheese talking point for a while, but it makes no sense except if we've all turned into little mouses now. With unemployment so high, where are the jobs that people are not bothering to take that bears any of this out? There's good money to be made in wingnutland, so she can attack Americans just trying to stay afloat by receiving unemployment compensation. I never realized how wonderful not having a job is.

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