Actually, That's Not Privileged Information
Know anyone -- maybe a patient or a family member -- who's taking an antidepressant to help with sleep, a relatively common off-label treatment prescribed by physicians for menopausal women? Or anyone who takes low-dose statin cholesterol-lowering drugs as a prophylactic measure against heart attack and stroke -- not to treat high cholesterol?
They could be hurting their changes of getting health insurance.
Insurance companies, as reported in a fascinating, alarming BusinessWeek article, are using prescription databases to weed out and screen out applicants based on their drug purchases.
This primarily affects people seeking individual insurance, not those covered under their employer's plan. Roughly 18 million people are covered by individual policies.
The article highlights the case of Walter and Paula Shelton of Gilbert, LA. When the article was published in August 2008, the Sheltons had recently applied for coverage to Louisville, KY-based insurance company Humana. Shortly thereafter, an employee checked their prescription profiles. At their local Randalls grocery store and Walmart, the Sheltons had filled prescriptions for blood-pressure and antidepressant medications. Medications used to treat mental health conditions, depression being one of them, are big red flags to insurers.
Actually, the blood-pressure prescription was for a minor problem Paula Shelton was having with ankle swelling. The antidepressant had been prescribed by her physician to help her sleep.
The Humana representative called the Sheltons to ask about the prescriptions. Walter Shelton explained that the drugs weren't for serious conditions, but the conversation "just went south," he said. The Sheltons were denied coverage.
Prescription Profiling
How does it work? MedPoint and IntelliScript are the companies that provide the prescription profiles, at a cost of only about $15 per search. They buy the data from companies called pharmacy-benefits managers (PBMs). PBMs have access to prescription information from drugstores. No privacy laws prevent the gathering of the prescription data.
FTC Crackdown
A 2007 investigation by the Federal Trade Commission (FTC) found MedPoint and IntelliScript violated federal law for years by hiding their methods from consumers. Not surprisingly, many consumers -- and even many insurance agents, according to BusinessWeek -- don't realize the insurance biggies, such as Humana, Aetna, Blue Cross and UnitedHealth Group, have access to applicants' prescription histories.
An FTC order required disclosure if information about prescriptions results in denial of coverage. MedPoint and IntelliScript say they are now fully complying with the order. And under the federal Fair Credit Reporting Act, the FTC mandated that insurers now tell applicants the address of the company that compiled the prescription data.
Privacy, Anyone?
Wondering how HIPAA fits into all this? When applying for coverage, individuals sign forms allowing providers to review their medical history. To be HIPAA-compliant, most insurers have now added a note that this also includes prescription history. Yes, it's in the fine print.
I understand that people with differing medical situations pay different prices for health insurance. When it comes to driving, a teenager or someone who's racked up a bunch of speeding tickets is going to pay higher premiums. Insurance, in large part, comes down to numbers, and I get that.
But what about when someone is denied coverage, like Paula Shelton, because she was following the advice of her physician? If this is the exception, not the rule, I foresee a bevy of Paula Sheltons.