After seeing Mrs. WhiteCoat argue on the phone with Medco representatives for 20 minutes about why one of her 80+ year old patients hadn’t received her medicine despite three lost faxes to Medco, I had to write this post to let the public know what is going on with some mail order pharmacies.

If you’re like most Americans, you want to try to save some money. One of the ways that patients can save money is by cutting prescription costs.

Enter Medco.

Medco is a mail-order pharmacy that receives prescriptions by mail or by facsimile and then sends patients their prescriptions by mail. Often, the prescriptions are for a three month supply of medications. By having warehouses instead of multiple “brick and mortar” retail buildings, Medco can save costs and presumably undercut the competition. An analogy might be that Medco is the “Netflix” of the pharmaceutical industry.

With the cheap prices come problems, though.

We probably see a couple of patients a month in the emergency department who have run out of medications because their shipment from Medco or some other mail order pharmacy hasn’t arrived. Most of the time the patients can’t get into see their family physicians and are just requesting a week or two worth of pills to “carry them over” until they get their shipment. Some patients try to split pills or take their medications every other day in order to hold out as long as they can.

Mrs. WhiteCoat is a family physician and she sees the other side of the Medco problem. When she faxes renewals for her patients’ prescriptions, her faxes are routinely lost. Doesn’t matter that she has a confirmation sheet. Medco makes her dig up the chart and re-send the renewal. Many times, she only finds out about the non-receipt of her faxes after her patients call her in a panic because they have called Medco’s customer service center, were told that no renewal was received, and are almost out of their medications.

Mrs. WhiteCoat also regularly gets faxes from Medco requesting that she change her patients’ prescriptions to a “preferred” medication. Unless she signs them and faxes them back, then calls to confirm with a pharmacist (not another physician) that patients really need the medication she prescribed, Medco won’t release the prescription and the patients don’t get their medication.

What’s the big deal — it’s only 5 or 10 minutes, right? Wrong. Many times it is more. Not too long ago, Mrs. WhiteCoat’s nurse was on the phone for 80 minutes getting prescriptions straightened out for 4 patients. That was time that the nurse couldn’t help patients in Mrs. WhiteCoat’s office and represented a loss of almost an hour and a half of the nurse’s salary to Mrs. WhiteCoat. Even if it is only 5 minutes, if you multiply 5-10 minutes times hundreds of patients, you end up with a significant amount of time each month of phone tag, waiting on hold during uncompensated phone calls, and hoops to jump through — just to get your patients their medications.

The mail order pharmacies may actually cost patients more money in the long run. If patients can’t reach their physician and have to come to the emergency department or urgent care center when Medco doesn’t get them their prescriptions in time then they may have to pay a copay or other out of pocket expenses for the extra doctor visit because of Medco shenanigans.

So if there is a mix-up in paperwork, or if Medco conveniently doesn’t get the faxed prescription for a patient’s medications (even though the physician has a confirmation page showing that the fax went through successfully), or if Medco pharmacists think another medication might be better for you than the one that your physician prescribed — you just might not get your medications before you run out.

If you don’t get your blood pressure medications and you have a stroke … well at least you saved a few bucks on your prescriptions – when you finally get them.

So a question for the attorneys. Suppose an insurer or employer’s health plan only allows their enrollees to get these mail order prescriptions. No prescriptions from local pharmacies or national chains allowed. Now suppose that a patient has a stroke because they didn’t get their medication refill in time.

Can the insurer or employer be held liable for contracting solely with a company that is suspect in its duties?

WhiteCoat is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.

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