(This piece is cross-posted at The Century Foundation’s Taking Note section.)
Mona Mangat has a nice post over at Doctors for America (a group I advise). Her column conveys some of the street realities of providing safety-net care and the value-subtraction entailed by our fragmented health insurance system:
I currently participate in 5 private Medicaid plans. Four of them require paper claims for reimbursement as well as onerous authorization procedures. I currently care for a 4 year old child with recurrent seasonal wheezing that has concomitant growth delays. I have attempted to treat her with a leukotriene modifier drug. Her private Medicaid provider denied my request, insisting that I use a generic nebulized steroid preparation. I engaged in a peer-to-peer review to try and get approval (that lasted 15 minutes over the phone), after exhausting 3 levels of paper prior authorizations. The friendly doctor I spoke with apologized that the drug could not be approved and when pressed for a reason, his answer was clear- COST. My patient will have to be placed on a medication that could further stunt her growth when a safer option is available, because her privately administered Medicaid insurance plan needs to make more profit.
Such stories indicate why everyone involved–insurers, patients, policymakers–desperately needs a legitimate evidence-informed process based on clinical judgment and comparative effectiveness research.
An expensive, potentially valuable drug is available that may greatly benefit a patient. The insurer doesn’t want to pay for it. It thus creates a process to either deny reimbursement or to make it more difficult, cumbersome, and unpleasant for doctors to prescribe this sort of thing. The doctor believes her patient needs the drug, and is willing to invest the time to pursue it. We need some legitimate, evidence-informed process to indicate whether and when such medications are reasonable to use.
Yes, this process will ultimately require some attention to cost-effectiveness. Some hard bargaining needs to go along with that, too. There is one missing element in the story: How much is the drug company charging Medicaid for this product? Is that reasonable? Costs and even insurer profits are valid considerations. These issues needs to be addressed through some transparent process that commands public legitimacy that protects people from the hidden and harmful forms of rationing Mona’s patient is now experiencing.
Insurers cannot address these issues on their own–in Medicaid or anyplace else in the American healthcare system. They have no standing to do that, even though in some ways that is precisely what they need to do in managing patient care. Their track record, particularly within the individual and small-group market, has not earned the public’s trust in making delicate judgments that balance issues of costs and patient well-being. The industry desperately needs some external referee that commands this kind standing.
That’s one reason why insurers should support a strong Independent Payment Advisory Board included in last year’s health reform. Ironically, that’s also a reason the industry should support serious public regulation of its own behavior. If the insurance industry fails to win greater public support and legitimacy, it will face a much more punitive reaction than anything included in last year’s health reform.
Finally, we need to raise Medicaid funding and reimbursement rates so that providers and Medicaid managed care plans have the resources to treat every patient and family with the humanity that everyone deserves. If it would be reasonable to demand that my child have the more costly medication to avoid stunting her growth, it’s reasonable to demand that Mona’s patient have it, too. We need to pay for that.