Cancer patients are being denied drugs, even with prescriptions and insurance
fresnobee.com
fresnobee.com
But as this article demonstrates, if we care to use the inflammatory "death panels" label, we already have them.
It makes me despondent that we can ever get to a place where our politicians can make rational, informed decisions about complex issues requiring multiple trade-offs. Cheap political rhetoric is not only easy to sell, stoking fear and tribalism is a winning strategy to getting reelected. 30 years ago most voters didn't bother to read a paper and were simply uninformed; now most voters are actively misinformed.
Why are you screwing around on Hacker News?
I don't know how to solve that.
I've been getting myself well (different condition) for years when that's not supposed to be possible. I'm quite open about that on the internet. I get attacked for talking about it and called crazy. I'm told "Produce studies backing up your claims" when there are none. No one is latching on to my story and going "What if she's on to something? Maybe we can do a study that will open up new treatment modalities for patients!"
I don't think it's as simple to solve this as you think it is. I don't know what needs to happen to break the herd mentality where humans don't seem to want to give any credibility to anything not already proven, which actively interferes with being able to prove anything new.
Presumably, taneq's point was that medicine owned by taxpayers can be sold at the cost to manufacture and distribute it at far lower costs, as opposed to the current system where the owners of the research also needed to be compensated.
https://en.wikipedia.org/wiki/Tofacitinib
Also, I think it's a valid question that doesn't deserve downvotes.
This says the exact opposite...
1949: Intra-occular lens
1958: ultrasound for obstetrics
1962: total hip replacement
1978: test tube baby
1986: combined heart, liver, lung transplant
1991: robotic surgery
2000: gene therapy for children with no immune system
2013: bionic hand
There are lots more.
The article ignores the R&D which often happened at private institutions and cherry pics the first use or minor refinement that occurred at a government facility.
It's not inflammatory when it's true. When the government runs our healthcare, choices are removed and someone else gets to decide if you should get surgery needed or not...and many times this is life or death.
At least now, if a cancer patient gets denied drugs, they can go to another doctor or get a second opinion.
All of my elderly relatives live in Canada and come over the border for any major surgery. This is mostly because the wait times are sometimes in the years..when they can just get private care in the US and get it done in a matter of weeks.
Doctors are also usually maxed out when it comes to patients, so individual care is lacking and they usually just want to try to push you out the door.
I also feel like I should have a say in someone's behavior, if I'm paying for their healthcare with my tax dollars: smoking, drinking, risky behavior, etc.
I've lived in countries with universal healthcare and the quality is sub-par compared to the US/private care. Sure private care can be improved, but it shouldn't be ripped out and replaced.
My experience has been the exact opposite. America's healthcare business ruined my life. As a result I have no insurance and have lost the "privilege" to BUY said American healthcare. I struggle with low income options and programs, all insufficient. The only good care I ever got was in Europe. My experiences with social hospitals and doctors was much better than in the USA where it counts. Places weren't often as fancy looking, but the care was superb. Even the private systems in those countries was far more affordable. a few hundred for an MRI etc rather than a few thousand.
Healthcare and education in America can bankrupt you. That isn't something people in countries with social options have to fear...despite any drawbacks since no place is perfect. I don't know if Americans who are so opposed to doing things like the rest of the first world just need to believe it's always better here so they ignore the benefits...or if they just haven't had to face this issue personally and are incapable of caring until they do. But I do know I had a future and now I do not...and there is no net to catch me or care. Whenever I see comments like yours I just get so upset realizing how it's an unwinnable battle in this country because of these ingrained beliefs.
"My experiences with social hospitals and doctors was much better than in the USA where it counts. Places weren't often as fancy looking, but the care was superb. Even the private systems in those countries was far more affordable. a few hundred for an MRI etc rather than a few thousand."
I pay for my own insurance in the US. I only pay a couple of hundred/month and most things are covered. My deductibles are very affordable.
There are plenty of option for low-income individuals and pre-existing conditions are no longer something that will prevent you from getting healthcare.
Even if you get a $100,000 bill, you can call the hospital up and negotiate it down to something you can actually pay.
"Whenever I see comments like yours I just get so upset realizing how it's an unwinnable battle in this country because of these ingrained beliefs."
I feel the same way about your comments. You have this ingrained believe that socialized healthcare is the best solution, when private care clearly has advantages.
The majority of people in the US are happy with their healthcare. There should be some additions, so people that can't afford care can get it, but without uprooting the entire system.
Life was greatly improved for those who didn’t have employer sponsored insurance and pre-existing conditions. And women of child bearing age. Now that they can actually get healthcare, someone has to pay for it, which is everyone.
You're confusing correlation and causation. Health insurance costs have been rising faster than inflation for decades, but the ACA actually slowed that growth through a variety of measures - one of the simplest being that insurance companies had to be paying for healthcare with at least a minimum percentage of what they charged in premiums - prior to that they could deny everything and put the savings into executive bonuses for performance.
Some reference points with links to source information, though you may have to look at news articles for 2018/2019 numbers. The Kiplinger article notes ~5% for 2019, still well below the 9.9% average between 83-92 or the 6.4% average between 93-2010. Post-ACA, prices between 2010-2017 ran ~4.3% average increases, so it has been creeping up since 2017 for some reason cough.
https://www.thebalance.com/causes-of-rising-healthcare-costs... this one has convenient table of annual increases over the past 59 years along with notes of what major event in that year impacted costs. Source is CMS data that's inconvenient to extract on a phone.
https://www.kff.org/other/state-indicator/avg-annual-growth-...
https://www.kiplinger.com/article/insurance/T027-C001-S003-c...
I don't think anyone argues that a royal palace is not a good enough home, the complaint is that only a very very few can live in a royal palace and if that's the country's main form of housing, a lot of homeless people are unhappy with it. You can pay for private healthcare in the UK as well. Pay as much as you like and get as many specialists as you can afford. The NHS doesn't stop that from existing. The NHS is probably lower quality care than that. What the NHS is, is available to everyone. The NHS was built in the 1940s /after/ it was already possible for wealthy people to pay to visit doctors of their own choice. Somehow that didn't translate into healthcare for everyone back in the day, and I'm not aware of any good argument for why it magically will now if we turn the NHS private.(?)
Your elderly relatives in Canada can afford to travel internationally and pay private prices for health care .. so national health care should be dismantled? What about the millions of Canadians who can't afford that, and a long waiting list is better than nothing?
Unsure of how popular this is. If it were, we'd see a lot more Us insurers offering plans to Canadians, but as far I know, they're non-existent.
Anywho, all this proves is that you can have a public system and a private system a 100km drive away if you have a problem with it.
You try to make do. Manage as you can with your savings, work you can get and maintain, as the effects of the medical issue continue to limit every aspect of your life and get worse with age and time. The normal decline of age is amplified as a result and your options to earn are further restricted. Eventually there is no way to do it alone or without some outside help.
You are directed to apply for programs that are also "privileges" and not available to everyone as the process is adversarial and not a right. You face many levels and months to years of denials, appeals, and are often completely rejected.Even if you get approved you are mired in bureaucracy, reapprovals, judgement, and your access is extremely limited even in the best case.
Next people you talk to about this will begin to marginalize you and act as if you must have done something wrong because they just cannot believe it's like that. In order to maintain their just-world hypothesis and feelings of security they need to frame this as an individual failure or anomaly and not a systemic and cultural defect.
You then start to get depressed and lose hope because there is no way to regain your quality of life or even obtain a survivable one in many cases. If you are fortunate enough to have caring family you might find some support and have some livable life, even if restricted. If you do not then you end up with more needs and expenses but with the exact opposite situation in resources. Eventually you decide to take a walk off a bridge because there is no real way out.
This isn't even the worst case scenario but rather a fairly median process because needs go up with age and resources decline so without having the time to build a safety net over a lifetime, or a social one being present...you have no options. This is happening to thousands of people right now. I am one of them. I've never met anyone like this who chose it or wanted it. I've never met anyone like this who wants to "sit on their ass and take my tax money" as people in my region assert. Every one of them is someone who had a life, who would love nothing more than independence, but for whom it isn't on the menu and neither is enough assistance to have any quality of life.
This is not true; if your insurance company will not cover a specific drug then going to another doctor will make no difference. And you can’t go to another insurance company outside of open enrolment - assuming your employer even offers plans from more than one insurer.
You can do this in any country with government provided healthcare by either going private or travelling to a different country.
> I've lived in countries with universal healthcare and the quality is sub-par compared to the US/private care.
Sure. The US spends more than anyone else on healthcare, but has worse life expectancy. https://ourworldindata.org/the-link-between-life-expectancy-...
It's stupid not to. We shouldn't plunder health care funds on $1m per year of life saved interventions when you can spend that on 100 interventions costing $10k per year of life saved.
It works pretty well (something like 15th longest life expectancy).
Of course, you're always free to pony up your own cash to pay for a treatment that isn't covered by your insurance, so the individual is always their own final death panel.
But an acquaintance with Canadian relatives told me he knows a middle aged single man that was denied a knee replacement he needed because of these trade-offs. Left with decades to live, partially disabled, because: "Old? No family? Well fuck that guy then."
Firstly, our social healthcare is actually pretty good for emergency procedures.
But there is only so much money budgeted per year for healthcare, and everyone in need competes for that limited pool, so there is a variety of ways care can be delayed or denied.
"Elective" procedures like hip and knee replacements can have long delays (queues) and seemingly odd requirements. One friend was "too" young: they had to wait for years in severe pain because they "shouldn't" need their hip replaced yet. Another acquantance had a record of hurting their knee as a young child: so they were not covered by ACC for knee replacement even though it was a ridiculous excuse in circumstances. Once a procedure is approved, you get reasonable treatment, and it is free.
There is a certain amount of gaming of the system - if you can find a sympathetic specialist you can jump the queue a bit. However that is a zero sum game, and it benefits those with time, intelligence and contacts (and screws some minorities).
Pharmac has a yearly government budget, and they choose which treatments can be afforded. We do the same with roading - cost benefit analysis is done for all roadworks and the best get funded until the fixed budget is met (small country, so one main roading department).
It is interesting that our two biggest healthcare insurers (maybe covering 80% of private insurance) are non-profit co-operatives: all premiums are either paid out in care or pay administration overhead. I think overhead works out to be about 10%. Fantastic system: pay premiums and don't get sick is winning, getting payouts is often actually losing. It's like a socialist system for everyone that has some disposable income. Private healthcare premiums are extremely cheap compared to the US e.g. "the premium for a member aged 0-21 years on our most popular plan, Wellbeing Two, is just $9 a week", and "Pay for 2 kids, the rest are free*"; you can see what is covered by that plan here: https://www.southerncross.co.nz/Portals/0/Society/EFulfillme...
It is disheartening to see anyone in any system suffer. I am quite sure if I was someone suffering in your example's case it would be hard not to be angry at the system. When it's you hurting you don't care so much if a system if overall better, better for others, or was even better for you 99/100 times thus far, prevents a bigger problem later etc...you just want to stop hurting.
And we especially shouldn't spend huge amounts of money on meds that don't extend life (or even shorten it), and that worsen quality of life.
With the big caveat that you cannot pay for "higher quality" of any services that are covered even if you want to.
Unless it's a life-or-death emergency (where the ED has guidelines to see you right away anyway), every Canadian has the option of paying for any level of service they want, even otherwise covered services.
Then there are the firms that walk the line and charge you as "preventative health" services.
Is that actually true? AFAIK (from second hand) there is no private insurance in Canada (i.e. far worse than e.g. UK), so you cannot get e.g. MRI by paying for it (and skipping the "official" waiting line of 1+ year).
As far as I know, none have tried. Either the demand isn't there, or there's a huge untapped opportunity (doubtful).
There are a few organizations that will arrange for your healthcare in the USA, but the Canadian demand wanting to pay to bypass the Canadian system isn't great. E.g. Cleveland Clinic has a Canadian branch, but just one office in Toronto.
It is OK if our politicians can't do this; it just means that, as the information age marches forward, we don't need politicians (or at least, that we don't need the state making these sorts of decisions).
I'm okay with the notion that tough choices have to be made. Especially if the rules are clear ahead of time.
But that's not the system we now have. The default answer is "no" and patients have to fight to get to "yes".
The real kicker is even people within the system (eg nurses, techs) struggle to get proper insurance and healthcare. If insiders are getting screwed, what chance do the rest of us have?
(FWIW, I've been denied various life saving treatments, scripts, etc. multiple times. I'm fortunate to have had multiple angels in my life who've gone to bat for me. eg FHCRC fredhutch.org)
In all cases, the patient suffers. They are already facing a medical condition, maybe serious, plus stress from missing work and home life, stress about the future, stress for paying for it all, and then along comes these sharks who will double it all with more stress and worry and anger. Then on top of that they don't get all the types and amounts of medicine their doctor actually wants, based on science and experience, so they will get inferior treatment in every way.
Yes we need to cut the price gouging. Adding friction at this interface is not the way.
It can also be the insurer saying "Nononono!" to treatments that are unnecessarily expensive.
Treatments are often chosen because of marketing, and not because of clinical guidelines. E.g. Blindly trusting a sales rep's "education", or choosing something new out of sheer boredom.
It gets dicey when the new treatment is a bit better, but a lot more expensive.
It’s abhorrent. Congress in making this law 50ish years ago essentially took away people’s right to sue and get justice in this instance. It was a huge gift to insurance companies and it needs to be fixed but people only learn about it when they are exposed to it. I wish there were politicians willing to step up and change this particular law.
When people talk about tort reform I think they’re really misunderstanding who such reforms benefit, as in this case it only serves the large companies and allows them to act in bad faith without proper repercussions.
My theory is specialists, hospitals, insurance and drug companies are trying to swipe everything that isn't nailed down before it all blows up.
I’ve never heard of an insurance company trying to reduce an insulin dose. They definitely pushed back on the number of test strips they would cover (e.g. 5 strips/day vs 7/day) where a prior auth was needed to get coverage at the higher quantity.
I have psoriasis and psoriatic arthritis. The barriers to getting a prescription for an effective (and expensive) biologic medication can be crazy.
When I've been forced to use a "specialty pharmacy", they require that the medication be shipped overnight (it has to be refrigerated) which is clearly more expensive than picking it up at a neighborhood pharmacy, that shipment has to be arranged every month, which means a phone call, waiting on hold, passing a quiz on my condition, surviving attempts to upsell supplies I don't need. They also won't ship "too soon", which inevitably means that the monthly refills slightly more slowly than once a month
I've also had insurance demand that I take ineffective but cheap medication for 3 months before I can get the stuff that works -- ostensibly they want to see if the cheap methotrexate (daily nausea, waves of fatigue) is effective.
In the 11 years since my diagnosis I've managed to be regularly on an available effective medication about 60% of the time, mostly because of this nonsense. 40% of the time I'm in pain
Edit: people don't seem too happy with this comment but it's a chance at legitimate relief from chronic pain with millions of daily doses in the US and no documented fatalities, excluding a handful of reports where other illicit substances were consumed simultaneously.
See quitting kratom on reddit for more info.
The difference? Humira is able to be given by self at home. Remicade requires an infusion by a nurse.
My insurance gave two choices: pay $800 out of pocket for the drug at any pharmacy that carries it (zero coverage offered, no recourse), take it to my doctor's office by hand, and get it injected there; or go to the ER and have it done one-stop there (at a cost of $300 to me and at least $3000 to them).
Fine, guys. It's your money...
Except it's not their money. It's all of our money, as the whole point of insurance is pooling resources to hedge against any individual risk. Not that I blame you - the implementation of some policies is completely asinine.
I completely agree. I think it's an absurdity that shouldn't exist. My point in sharing my anecdote was to validate the prevalence of the absurdity that my comment's parent observed, though I probably could have been more explicit about that.
Notwithstanding, this is only possibly true under a model where everyone initially has equal opportunity. A weak requirement that is almost certainly insufficient, and yet one we have already failed miserably at.
[Edit] obviously it would be cheaper to self administer, but the costs involved aren't rational anyway. These drugs are out of patent, but no generic can be created because of the way they're made, so Abbot et al can charge whatever they want
One example story (but you can find many more I'm sure): http://www.papaa.org/articles/dead-sea-personal-report
I have no idea what I'll do after that.
Perhaps you could also get your doctor to write a new prescription a week earlier, so you'd have more of a buffer.
[0] Just to be clear, I'm not trying to sing any praises of CVS. I've only dealt with them because they just bought out another specialty pharmacy which I also had a short experience with. That consolidation is presumably another symptom/cause of the ongoing dumpster fire. I'm just trying to offer pragmatism to perhaps better cope within this broken system.
addendum: I've no idea why I'm being downvoted. Is the only goal of sharing personal situations simply to pile on the outrage party? Obviously OP has been at it for a while, and in that sense should have their own situation figured out the best for themselves. But OP is probably overloaded with stress due to the situation and is just thankful it "works" at all, which results in clinging to local optima.
shrug, I see another comment referencing that CVS is mentioned in the article (my "article" says "Access Denied"), so perhaps pointing out that they do actually do their job some times clashes with that.
In terms of shopping around, the most effective tactic for me is to find the job with the best insurance
I had thought there would be more specialty pharmacies, with the real need for them just being that those drugs wouldn't be stocked at every single branch in case someone needs them. I've personally seen competing offers (in my situation, the PBM is not CVS, and has its own mail-order pharmacy so it encourages you to switch), but haven't had to investigate them because CVS is still working fine. But why would CVS be buying up other "specialty pharmacies" if they weren't a racket of one kind or another.
Maybe insurance companies act less shitty when they're tied to Medicare (this is actually for my father), or maybe I'm also in a glass box and haven't yet noticed the walls.
Which well, is the general problem with all the ongoing political dumpster fires. "Looks fine to me" say the people who just haven't run aground yet. I do apologize if I came off that way.
The big drawback is that your employees would need to live near Kaiser facilities. In the Bay Area they are everywhere though and easy to get to. Making use of any doctor or service outside of the Kaiser network is probably not covered.
At least they'll be encouraged to dispense more at a time (3mos vs 1month) to save their time and yours.
What I do now is have my Kaiser doctor give me an old-fashioned written prescription on paper, take it to the Kaiser pharmacy that is in the same building as the doctor's office, and ask them what my out of pocket cost will be. While they are figuring that out, I look up my non-Kaiser options in the GoodRx app on my phone. When I get the cost from the Kaiser pharmacy, I can then decide where to actually have it filled.
It was similar before I had Kaiser. The Walmart cash price or the GoodRx price was often less than my copay with Premera or LifeWise if I used insurance.
I've heard good and bad, mostly bad, from Kaiser. But it's hard to tell objectively given the current system and how people interact with it. Personally, I had a not so great experience.
After spending a billion or so on meds we found out that they mostly don't increase length of life and also cause nasty side effects. https://www.bmj.com/content/357/bmj.j2097
Clinical Commissioning Groups should be following NICE guidance. If NICE looks at a medication and says it doesn't provide enough advantage for the cost they won't recommend it. That means CCGs won't always pay for it, and so hospitals can't use it.
Sometimes when NICE recommends a treatment the patient has a legal right to it, and the patient can pursue treatment if their local CCG is trying to avoid paying for it.
This cost:benefit calculation appears to be what's happening in the US. Except over here it's a public body making the decision and over there it's a private company.
Here's the NICE page for Pomalyst: https://www.nice.org.uk/guidance/ta427
> Pomalidomide, in combination with low‑dose dexamethasone, is recommended as an option for treating multiple myeloma in adults at third or subsequent relapse; that is, after 3 previous treatments including both lenalidomide and bortezomib, only when the company provides pomalidomide with the discount agreed in the patient access scheme.
That seems similar to the US? Only to be used after other meds have been tried, and only if the company supplies it at a previously arranged discount. (I didn't do much searching for this so maybe I've misunderstood the NICE guidance).
https://www.nice.org.uk/corporate/ecd4
> If NICE recommends the use of a treatment, the NHS Constitution says that it is your legal right to have it if your doctor believes it is right for you.
https://www.gov.uk/government/publications/the-nhs-constitut...
> You have the right to drugs and treatments that have been recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you.
And here's a list of those treatments: https://www.nice.org.uk/guidance/published?type=hst,ta
People complained that their doctors weren't allowed to go off-track and make up special treatments for their special patients that went against guidelines (like the patients in the article).
Because it's political suicide to deny "What the doctor thinks is the best" when it comes to dying cancer patients, the UK government set up a special fund of money to let doctors go against the guidelines. It accounted for ~1/6th of all cancer drug costs.
It turns out that this special fund was largely a waste of money, the guidelines were fine all along, and patients were harmed by getting treatments that don't work.
Despite having our hearts in the right places, patients were harmed, and funds were taken out of some other (proven) part of the health care system. But because we tried to help, we won't bring this up very often.
Ultimate, what is described is an insurer tying to minimize the payout on a claim same as they have been doing from the dawn of time except here it's particularly nasty as people suffer and die.
Where in the article says that the insurance provider was trying to minimize the payout on the claim?
Insurance companies really hate paying for things that don't work (or have a low likelihood of working). Even more than paying for something expensive that works.
The article is really annoying, because Treatment A didn't work, and they wanted to skip Tx B and go right to Tx C. Tx C worked, but the article never named any of the drugs, so we can't evaluate the validity of this guideline. We just have one anecdote of one event where doctor was ultimately right (because nobody runs to the LA Times when they were in-the-wrong).
The reason given: The patient should have surgery to remove his kidney first."
Either the issue is:
1) Kidney removal shouldn't be a course of treatment (unknown based on the details provided). Keep in mind, the same insurer would be paying for this, and it isn't cheap, so it's not as ridiculous as it sounds.
2) Patient status with regards to surgery wasn't communicated to the payor, but should be a part of that process. Or it was a part of the process, but it was omitted.
3) Kidney removal should be a course of treatment, but the doctors didn't want to go through with it anyway, and made up some reason after-the-fact to continue to support their beliefs.
Yes, but having a PBM tell a doctor that their diagnosis is wrong and try to change their professional recommendation, without ever having seen the patient, and with unknown qualifications, is downright evil and probably malpractice.
We have doctors for a reason. They took a hippocratic oath to do no harm, and allowing unqualified people who took no such oath to tell someone to "just take out the kidney" is abhorrent.
Knee arthroscopy is a good example where doctors knew for a fact that they were helping patients until we ran trials using sham surgery and we found out it doesn't help some patients at all.
https://www.painscience.com/biblio/fascinating-landmark-stud...
https://doctorskeptic.blogspot.com/2012/08/placebo-surgery-4...
PBMs are probably bad, but we need some organisation to look at the evidence and say whether something works or not.
Not as common as you think.
I don't agree with drug laws related to addictive substances. But at least they make sense. Even laws related to antibiotics. There's potential for abuse, so the controllers at least have a logical (if not reasonable) argument.
But what possible purpose does it serve to require a prescription for insulin? Or chemo drugs which have no pleasant effect?
The blatant racket isn't even questioned when things like this happen.
We should be lobbying to remove the need for prescriptions from most drugs and to remove liability for drug sales from pharmacies and other third parties. This way, they don't have a say. And they shouldn't.
America is a place where the 0.1% probability there is a negative reaction means 25% of the population can't access medications. And they have the chutzpah to say it's for our own benefit. Legislative capture at it's worst.
My current treatment regime is based on a research paper. My insurance initially denied me treatment based on "an expert in the field" and stupidly listed the doctors name. I looked her up and she was a podiatrist...
For the most part, my treatment is dialed in and mostly working. But I had a solid three months of fighting with the insurance company to get all of the medications, and I do the monthly phone calls to three different specialty pharmacies to get all of the various things that keep me able to walk.
Its a crazy hard problem because one of my medications is a "failed" cancer drug. Tens of millions of dollars worth of R&D, several clinical trials, and it turns out it doesn't work on most common cancers. (And even on cancers it does work on, its usually used as a Hail Mary play, at EOL because it might give someone a few more weeks, maybe). It costs roughly 40k a month, and I might be stuck on it for the rest of my days.
Certainly those that failed with the exotic treatment plans won't be around to complain about it.
Its product is perfect, the only alternative the customer really has is to live in discomfort or die.
Its prices are fully unregulated.
The care providers are fully utilized and can therefore practice pretty much the prices they want.
The insurance companies are consolidating and can therefore practice the prices they want, while providing an ever dropping level of service. Consolidation with pharmacies even give them a way to control the distribution and a way to recover some of their disbursement.
Pharmaceutical producers are protecting their markets through patents that give them monopolies, which combined with a total absence of governmental overlook lets them practice the prices they want. The more the patient needs the medicine, the pricier drugs can get. The incentive is then that the deadliest the disease is, the priciest the drug gets.
The only balance that should exist with insurance weighing for lower treatment costs ends up being lower reimbursement and more borderline control on the patient.
Truly this is a perfect system, ever more efficient at extracting money from people suffering. All the incentives are in, just not weighing in the favor of patients.
Since it will be impossible to provide everyone with the best health care, it'll get allocated according to bureaucratic rules, not what you or your doctor want.
These allocations will inevitably be done based on political decisions, and how politically connected you are.
In national healthcare, it isn't you who decides.
Insurers come up with formularies that favor less expensive drugs first. If those don’t work, the patient can get the more expensive drugs.
Manufacturers negotiate formulary agreements. They might offer a rebate to move their product to first line use.
In therapeutic areas like psoriasis, the rebates can exceed 50% since it’s such a competitive class with more than a dozen products.
When I was in the insurance business, formularies were very common, as I imagine they still are based on my experience as a customer of an insurance plan. Whether or not a drug was on the formulary list was both knowable in advance and negotiable. If your doctor wanted to prescribe something to you that wasn't on your plan's list and had a good reason and felt like having his or her staff spend an hour on the phone once a quarter, your insurance company would often permit it. Funny enough, Anthem--discussed in the article--was one of the better ones in the past about having flexible formulary rules. Even if your doctor wanted to go off-label with an unlisted drug, the majority of insurers would cover it in some way.
This use of PBMs, where drugs are on the formulary list but the doctor is told "nope, you can't prescribe that right now or in this way or in this quantity" and being overruled by a pharmacist at the insurer, is relatively new and scary.
(Incidentally, this is why the rhetoric of "death panels" during the debate around the Affordable Care Act was bullshit. We've always rationed care in this country and, in the private insurance market, how it is rationed is almost always completely opaque.)
However, some control is needed. I was talking to an insurer once and he mentioned a doctor who had prescribed a drug for patient where there was no evidence it worked. When he asked the doctor why, he said “well I have to give them something”. This was a $10,000 per month drug.
When navigating systems like these you have to find ways of looking like the 90% even if you’re in the 10%. Any exceptions to their protocols will be met with resistance and delays as you have to make your way to some review board vs. dealing with the mindless lower level staff who have no decision making ability.
It’s what happens when you have executive management with MBA’s that have come from running customer service, consumer finance and call centers running health care.
That delay is what can be the difference between life and death for some.
Not only does it damage patients' health, but it increases physicians' non-reimbursed costs.
The qualifications to become a pharmacy benefit manager include a bachelor's degree, at least five years of experience as a pharmacist, and five years in health plan pharmaceutical management.
So a bozo pharmacist can trump a doctor's judgment.
They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is covered under the plan rules.
Not how it is described in the article. Is the article incorrect in your opinion?
Presumably not "whatever they want", presumably it's a bit more structured then that.
> The third party payer is also free to object
Aren't the patients payers too?
Read the article, it's nice.
I think it’s incorrect to say they don’t trump the prescribing doctors judgement just because they have a company policy they’re following. They also have the ability to override the policy. This means they are making a decision and when they default to what the policy says, if that goes against the doctors judgement then that is a decision they made to trump that doctors judgement.
This kind of “just following orders” logic is used a lot by people who want to absolve themselves of the responsibilities of their choices.
From my understanding, they do not. At least not outside of a certain margin of error, since the payer (for example a state government or employer) would then blame the PBM for approving payment something it wasn't supposed to approve payment for, and hence seek reimbursement from the PBM or cancel its contract and go with another PBM.
My whole point is that blaming PBMs is a waste of time. With or without PBMs, someone working at or for the payers (employers, insurers, governments) will be approving and denying claims, just like they have to for home and auto and any other insurance claim.
The correct person to blame is us, the voters, for not voting for taxpayer funded healthcare for everyone. But even then, there will probably be some type of setup to ensure healthcare providers are not abusing and defrauding the system, hence someone to approve and deny payment from the government.