It is no secret that the world of insurance is changing at a rapid pace. We have discussed the burden this places on healthcare providers and patients, but the recent story of Yarushka Rivera poses new questions for us all and should remind us of the preeminence of patient care. In October of 2012, the family of Yarushka Rivera sued Walgreens, their primary care doctor, and his practice group alleging the wrongful death of their daughter. The question before the court: Does a pharmacy have an obligation to help a patient be sure that insurance will cover a prescription? Rivera suffered from epilepsy and took the drug Topamax to manage her life-threatening seizure.
Prior to her 19th birthday, Rivera and her family were able to get Topamax from their local Walgreens since their insurer, MassHealth, covered the drug. That changed in 2009 when Rivera turned 19 and the family was informed that their insurance provider, MassHealth, would no longer cover the prescription without a doctor's pre-authorization form. The staff at Walgreens told the Rivera family that they would have to pay the $399.99 for the medication out of pocket. Unable to pay the full amount for the drug, the Rivera family waited as Walgreens said they would fax their doctor to request a pre-authorization form for the prescription. Rivera had three strokes as the family tried to obtain the pre-authorization form. The third stroke was fatal and she died in October of 2009. According to the doctor's testimony, a request for a pre-authorization form was never received in spite of the Rivera family visiting the pharmacy on five different occasions. An expert witness testified that patients asking a pharmacy to request pre-authorization forms on their behalf was "typical of the industry", but Walgreens, in spite of having implemented a system that would fax the pre-authorization form with a single mouse click, denied that they had a legal obligation to contact the doctor. Two lower courts of Massachusetts agreed with the pharmaceutical giant as Walgreens successfully avoided trial by moving for and being awarded summary judgment in the case. In the second ruling, Judge Dennis Curran of the Superior Court stated, "Merely telling Ms. Rivera and her family that it would contact [her doctor] does not create a legal duty because Walgreens pharmacists expressly instructed her and her family to contact [the physician themselves] which they did apparently to no avail." On Thursday, June 7, the Massachusetts Supreme Court overruled both lower courts stating that Walgreens had a "limited duty to take reasonable steps to notify both Rivera and [her doctor] of the need for prior authorization each time Rivera tried to fill her prescription." Though not required by law or regulation to facilitate the receipt of the pre-authorization form on behalf of the patient, the court stated "it is evident they have some role in furthering the well-being of their patients and are well suited to assist patients with certain issues regarding their medication... The skill and knowledge of pharmacists today involve more than the dispensing of pills." Rivera's case will now move forward, but perhaps this is a good reminder for us all that times have changed. You can't shift the responsibility to someone else. You have to own responsibility (no matter how frustrating) to help your patient. The patient says they tried to call the doctor, maybe they should have been more insistent? The pharmacy should have pushed back on the doctor or insurance company but that takes time and energy. The insurance company is putting in a policy that says they supersede the judgment of the doctor so now the doctor has to jump through hoops using time and resources to fill out papers so that the pharmacy can make money. It is easy to become frustrated with all the red tape and paperwork we encounter on a day-to-day basis as doctors, but the best possible care for our patients should always be prioritized over our inconvenience or annoyance with the system. In the end, and regardless of who is ultimately deemed responsible, a patient died because she and her family could not get a piece of paperwork. Just as the Massachusetts Supreme Court noted that the skill and knowledge of pharmacists exceed the dispensing of pills, the role of a doctor exceeds writing a prescription and filling out a form. The call in light of Rivera's death is that we go the extra mile for the well being of our patients regardless of the situation. How do we ensure a similar situation could never happen in our practice? Do we have the right systems and process in place to follow up with our patients and check in with them? Maybe the better question is, are we truly empathizing with our patients in their situations? We can think poorly of Walgreens, the insurance company, or the doctor, but everyone needs to take responsibility and take initiative to do what's in the best interest of the patient.
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August 2019
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