Saying 'no' for insurance companies

"I just felt so terrible all the time."

FORT COLLINS, CO - OCTOBER 24: Comcast employees taking online classes to learn to handle calls from Comcast costumers on October 24, 2017. (Photo by John Leyba/The Denver Post via Getty Images)

The United States is not really a country, but it’s a very good place to buy things. We have a consumer culture, built around having what you want, when you want it, and with extra cheese. Have It Your Way™ might as well be on the dollar bill. This situation requires a strong customer service culture, where the customer is always right. They have to be, or otherwise they might not keep buying things. Right?

Not really. Customer service workers are extremely nice; you certainly notice that here as a British person. (Americans are extremely nice in general!) But they are also frequently unable to help you. If you have a complaint that is the company’s fault, a lot of the time it would be costly to fix it. And if they don’t have much reason to—like, for example, if there isn’t any competition, or they have no fear of accountability through government action—it’s often cheaper to not help you at all. They’ll have a customer service phone number, sure, but you’ll wait for an hour on hold and eventually be told, thank you so much for being a customer but I’m afraid there isn’t anything more we can do today, ma’am. They have a buffer of underpaid workers with little power—both in determining their own working conditions and in actually doing much for any customer who has a problem that is even slightly complicated or would involve the company losing money. It’s a bad deal both for the worker and for the customers they’re supposed to help. There were three million customer service workers in the United States in 2019, with a median salary of $34,710. It’s a hard job that sucks. There’s a reason Sorry To Bother You was set in a call center.

All of this takes on a more dystopian and infuriating cast when it comes to private companies that provide services the government ought to be providing. Like when you call Comcast about a problem or a mistake on your bill, and they have to try and sell you on getting a damn landline phone in 2021, and you think—why is an enormous and hugely profitable private company the only way to get internet service, something that is at this point clearly a utility and required for participation in human society?

Or, like when you call your health insurance.

Today’s interview is with Emily—a pseudonym, to allow her to speak freely—who worked for two years as a customer service advocate for a major pharmacy benefit manager. (She got a new job last year.) Companies like the one she worked for are contracted by health insurers to manage the prescription drug benefits for their customers. That means if a patient has a problem with their prescription, or needs a mail-order or specialty drug, people like Emily take the call.

Callers can be awful to workers like Emily, of course—perhaps to be expected, though not excused, in high-stakes, stressful situations where you can’t get your meds. But the reason Emily eventually left her job wasn’t customers yelling over the phone, she told me—it was because she “felt so terrible” being part of the machine that denied people medications they needed. She said she would deal multiple times a day with customers who couldn’t afford their medications. (Remember, even small increases in co-pays cause people to drop life-saving medications.)

When someone called in saying they couldn’t afford their meds or they weren’t covered anymore, there weren’t many options available to her. Some people qualified for a manufacturer assistance coupon, but many didn’t. She could suggest taking a different medication or a generic, but most of them had already tried that, she said. (Why should they, anyway, if that’s what their doctor had prescribed them?) For a lot of people, she just couldn’t help them. And then she had to hang up the call. Click; and they’re gone, back to their lives and their struggles. That was her job, a job she needed to pay the bills, just like everyone else.

She was deployed, like a guard at the gates, to enact and enforce the awful logic of the healthcare system; if your insurance plan happens not to cover your drug, you don’t get it, thank you for calling and have a nice day. The executives, the ones making millions of dollars a year, don’t have to tell customers that over the phone over and over again. They deploy people making $35k to do that instead, to end up with customers yelling at them over the phone because their meds aren’t covered. It’s a fine way to break down solidarity among the lower-income in this country, if that was on your agenda; employ low-income people to say ‘no’ to other poor people for you.

Emily made $15.60 an hour. A little over double the minimum wage in her state, sure, but not enough to make you rich or even comfortable. Just enough to keep you going into work.

Emily: My job title was Customer Service Advocate, and basically what my job duties were, I had to talk to customers—well, we referred to them as customers, which like, I hate that—we had to answer any questions they had, if we had to call a pharmacy or a doctor’s office for them I would do that. If they needed to place a refill for their medications through our mail order system I would do that. Eventually it got to a point where I just spoke to other employees, and I helped them with any questions they had.

Sick Note: How often would you say you were fielding questions from “customers” about the affordability of their medications? What were the kind of things they would call and say?

Emily: Several times a day, definitely. Definitely pricing was a really really big one. People would ask why a medication isn’t covered, especially if it was covered before, or they would ask why it needs a prior authorization when it didn’t need one before. Or they’d ask about a new medication—how much is this going to be, is it covered or not covered, what steps do we need to get it covered. Those are the most common questions.

Sick Note: Would you say patients had a lot of problems with things like prior authorizations and questions of getting specific medications covered, was that a particular source of frustration for them?

Emily: I would say definitely, that was a really big source of frustration, especially since it’s really hard to explain prior authorizations, because they’re kind of silly—they’re basically like, well, we have to ask your doctor [if] they actually said that you need this. So a lot of the time I would explain it and they would be like, why do you need a prior authorization, my doctor said that I can take it? And I was just like… Now I gotta explain it using the company jargon that’s basically like, “well, this has a prior authorization for your insurance, and you know, we do have to confirm with the doctor,” and all of that. So it is frustrating, especially since it is just a lot of red tape, honestly. A lot of people know that, too, so it’s like you’re trying to bullshit them, but they already know that it’s bullshit.

Sick Note: Would you say that the requirement to use the company jargon and go through the red tape made it hard to really connect with and help the people you were talking to?

Emily: I would say so. There were a lot of times where I would really wish I could tell someone, you know, this is really arbitrary and it’s stupid, but I have to do it. Obviously you can’t really say that on a recorded line. There were a lot of times where I wanted to say, I know this sucks and it’s stupid, but please level with me, I can’t do anything else. But you really can’t say that. 

Sick Note: Were there specific types of medications that you noticed were often causing people problems with affordability or prior authorizations?

Emily: Insulin was number one. A lot of people I spoke to needed to take cheaper versions, or they would need to use manufacturer coupons, which you can’t use if you’re on Medicare or Medicaid, by the way. So you’re just kind of SOL in that regard. Insulin was a really big one, I feel like the second most common that I would see was if people had to take brand for anything, like if they had to take a brand seizure medication or a brand antidepressant. Those generally were the second most expensive. Insulin is definitely the number one that I saw.

Sick Note: Would you say it was common for you to say to patients, I know this is the medication your doctor prescribed, but if you can take a generic, or a different kind of the same medication, it would be cheaper?

Emily: Yeah, that’s actually one of the things they recommend us to offer to patients. Especially if something is too expensive. I would say probably more than half the time they would tell me, I can’t or I already tried that, or I’m allergic to it, whatever the case may be. So it was kind of giving them advice that wasn’t really helpful, but unfortunately there’s not really a lot that we could do for them. But we were kind of positioned in a way in which we were told that we could do more for them than we really could. 

Sick Note: How does that make you feel, being in this position where you were trying to help people while knowing that you really couldn’t?

Emily: It made me feel really awful, and really hopeless. It makes you feel like you’re part of the problem, even though my insurance had the exact same issues, I worked with people who had the exact same problems at work. We had the same insurance, we live under the same system as everyone else, we’re not special. But at the same time, you feel like you’re the exception, and you’re this evil person. You’re not, you’re just a person trying to get a paycheck and like, live. But it makes you feel like a terrible person. It’s why I honestly couldn’t do it anymore because… God, I just felt so terrible all the time. I felt so guilty.

Sick Note: Did the company have any kind of specific policies or guidance on what to say to patients who had trouble affording their medication—like a script, if someone calls and says, I need to cancel this medication because it’s too expensive?

Emily: We didn’t have a very strict script, I know we did for the intro and outro of the calls, but the rest of it was basically like, here’s a general outline of the order that you should do things. But there wasn’t a really strict script, which was kind of nice. Generally they encouraged us to try and help them find options before telling them we’ll go ahead and get that prescription removed for you, especially if it’s something really important like insulin or a seizure medication. If it’s something like an allergy medication, sure, but generally that’s not what people were asking about. We try to encourage them to go through any other options, an alternative; try a manufacturer coupon, if they’re taking it twice a day, that can up the price, see if they’re able to get it once a day. If none of those work, ultimately we have to accept their wishes, and we would have to request that a pharmacist remove it from their account. 

Sick Note: How big a proportion had a happy ending where someone said, I can’t afford this, and you were able to actually find them a different option? Or how many just ended in them hanging up?

Emily: I would say most of them went more towards the, I can’t afford this, and just ending the call type situation, especially because if they’re taking a brand, for example, they’ve probably already tried different generics, because they were probably required to, or if they’re taking it multiple times a day or taking higher doses, they’ve probably already tried lower doses. These are people who have already tried all those options, and you’re basically regurgitating those options, and they’re not really helpful at this point.

Sick Note: Would you say working this job changed how you saw the healthcare system?

Emily: I would say yes. For the record, I was already very pro-free healthcare before working there, so that didn’t help because I was already disillusioned with the system. But it’s different when you’re looking at it from the inside, and you’re talking to so many people who are impacted by it, and you can’t avoid it. I’ll see so many people, like on Facebook, saying “I’m so tired of politics,” and they can avoid that. But when you’re working that every single day, you literally can’t avoid it. So I think it was just that reality of like, God, this really sucks, and this hurts so many people. It just rocks you.