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A Case Study in Access to Obesity Care

Ever wonder why people who are seeking evidence-based care for obesity cite access to care as a key concern? Consider this case study in access to obesity care.

A patient with with a strong family history of obesity, diabetes, cardiovascular disease, and stroke was first prescribed orlistat twelve years ago. Even after seeking pre-authorization, coverage was denied, so the patient paid out of pocket for the prescription until orlistat became available OTC. The cost went down, but still, for the Rx dose, it was about $120 per month.

All went well for about a decade. The patient, whose weight had once reached into the range of obesity, stayed in a healthier range of overweight.

When the OTC product went into short supply in 2014, the patient had to go back to the prescription product. He was surprised to learn that his prescription plan would now cover the Rx product with prior authorization and it would only cost $15 per month out of pocket. That was a good thing, too, because the cost of the Rx product had gone up to more than $500/per month. No doubt that has something to do with supply and demand.

A year later, another twist came when the prescription required a new pre-authorization for insurance. For some reason, the doctor responded to the pharmacy that the orlistat was optional. “Coverage denied.”

When the patient asked the doctor, the doctor replied, “We can control your cholesterol and blood pressure with real drugs. And besides, they’ll never cover the orlistat anyway.”

After further discussion, the doctor agreed to complete the needed paperwork, saying, “When they turn this down, I don’t want to talk about this ever again.” A week later, the prescription was filled and the co-pay was only $15.

This is just one small example of how “the system” erects barriers for the few people who are seeking real medical care for obesity and its health consequences. Many people have much bigger fights with their “health” plans over much bigger sums of money. Changes come incrementally and it takes everyone in the system a long time to learn new ways.

Perhaps more people will seek care when we stop frustrating the people who are already making the effort.

Click here and here to read more about access to medical care for obesity.

No Public Access, photograph © Fuzz Caminski / flickr

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July 28, 2015