Sicko Discussion: Many Nays, Few Yeas

June 28, 2007 · Posted in Domestic Policy · 1 Comment 

I’ve been following the discussion surrounding universal health care and Sicko closely over the past couple of weeks. It’s interesting to me to see the polarity of opinion around the question of how best to deliver health care in this country.

One thing is sure: Reasonable, open discussion of the issues with solutions attached is nearly non-existent. Reactions range from “Universal Health Care will doom this country” to “Universal Health Care is the solution to all of our ills, physical and otherwise.” Where is the middle ground here? Is there a starting point? For me, there is.

dn lpnsk, via Flickr

The three-pronged profit pitchfork of our current healthcare system:

  1. Pharmaceuticals: Rising costs associated with medications and delivery
  2. Malpractice Lawsuits and uncapped damage awards
  3. Insurance Companies – Profit-taking Enterprises posing as non-profits with extraordinarily costly administrative layers

Starting with a reasonable dialogue about how to limit the financial and political control that the three groups associated with the three prongs named above have on the reform process is a good place. Three of the most powerful lobbies in Congress are represented there. It seems to me that to have a reasonable dialogue about access to healthcare at a reasonable price, there needs to be a commitment (or revolt) that excludes any interest other than the national interest; that is, the citizens of this country and their need to receive healthcare at some sort of reasonable price.

Michael Moore drives home how loudly the money talks. When he points out that there isn’t a single person in Congress who hasn’t received funding on some level from the companies with a vested interest in the status quo, I was tempted to throw my hands in the air and give up before even beginning. But I think we can make this work.

The following links all came by way of Kevin, MD, who does a great job of linking yeas and nays alike, though he tends to lean away from the universal healthcare system proposed by Moore. (I’m not sure I’m sold on it either, at least not if the administrator is the federal government). Here are some of the ‘nays’ I’ve read in the past few days:

USA Today, June 21st:

Sicko uses omission, exaggeration and cinematic sleight of hand to make its points. In criticizing politicians, insurers and drug makers, it says little about the high quality of U.S. care. In lauding Canada, Great Britain, France and Cuba, it largely avoids mention of the long lines and high taxes that accompany most government-run systems.

In fairness to the authors of this op-ed piece, they do make an effort to present a balanced view, but overall this quote states the premise of the author’s opinion. However, what they miss is that the quality of health care in the US isn’t relevant to people who have no access to it. This is the crux of the issue to me — we have to find a way to open the lines of access to healthcare and do it without bankrupting individuals or the country.

WizBang writes:

I do not believe that we have a health care crisis in the United States.

I do believe that we have a serious problem with the financial aspect of the health care industry.

I also believe that the biggest contributor to the health care financing crisis has been lawyers.

Personal injury lawyers like John Edwards, who can claim a large portion of the credit for crippling the obstetrics field in his home state.

The cost of health care has skyrocketed in the last few decades, while the actual income of physicians has not kept pace. In some cases, it’s declined tremendously. That means that a lot of money is going into the system is getting sucked out before it reaches those who actually provide the services. Some of it is leeched out by the personal injury lawyers, both directly (through lawsuits) and indirectly (through malpractice insurance premiums).

Some of it is sucked up by the tremendous bureaucracies instituted by the insurance companies, whose purpose is to minimize how much money gets through them to doctors and other health care providers.

Some of it goes into the increased overhead of doctors, who have to comply with zillions of regulations from health insurance companies and the government.

While I agree with some of what Wizbang writes, I disagree with the statement that we are not nearing a health care crisis in this country. We surely are heading in that direction. Less students are applying to medical schools. More doctors are leaving active practice for academics, consulting, and other areas of practice which relieve them of the need to pay exhorbitant malpractice premiums, expanding their payroll to include employees to manage the administrative red tape involved with insurance companies, and being paid less to do more. The students who do go to medical school are heading for specialty practices more often than not, leaving our family practices without general practitioners.

Yes, we are heading toward a crisis, Wizbang. But you’re right about the contributors to it, for sure.

On the other side of things, The Health Care Blog rightly points out that making a change is hardly as easy as snapping our fingers and making a new system:

A big problem I have with those who now advocate moving to a single-payer system is how really poorly thought-out their proposal is. Proponents seem to presume that you can get from Point A to Point B in one easy move.

The problem is that since 1965 those who operate in the the U.S. health care system have become something akin to drug addicts–they are addicted to all the incentives we have–good, bad, and perverse.

Both are excellent points. In the 1970′s a similar dialogue was taking place around pension and retirement security, and how best to reform the pension system in a way that was fair to employers and employees and would provide some measure of retirement security to all. Sen. John Erlenborn led the way to the passage of ERISA — a sweeping reform of how benefits were to be administered and delivered, how retirement assets were to be protected, and minimum requirements for the operation and administration of pension plans.

Despite Congress’ addiction to amending the pension laws every 2 years or so, the foundational spires of ERISA remain intact: No discrimination against employees; trust assets must be for the exclusive benefit of participants; vesting and benefit accruals must be earned over a limited number of years, and employees must receive annual disclosures and statements related to their benefits. There are other provisions, but these are the basics. By stripping retirement security down to the most basic level and starting there, a plan could be developed for implementation that actually delivered results.

We need to do the same thing with our current health care system. Take what we have, figure out the most basic requirements going forward, and then find a way to deliver those basics fairly and economically, which may mean forming some sort of foundation (non-profit) outside of the government but accountable to administer it.

There’s much more to be said. This is just the beginning. I’ll be posting updates with opinions pro and con as I have time. Or you can save me some and post a comment here to start things off.

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Sicko: Can Socialism Fold into a Capitalist Society?

June 19, 2007 · Posted in Domestic Policy · 4 Comments 

Michael Moore’s new film “Sicko” is a must-see for everyone, regardless of party affiliation, regardless of how you feel about Moore, and regardless of where you stand on the state of health care in the United States. He presents a picture of health care in our country that strikes a chord and resonates in one way or another. For me, his call-out of insurance companies and pharmaceutical companies’ incessant rape of the health care system in the name of higher profits got a high five and then some. He does a great job of choosing out the inequalities in the current system without flinching.

After a stellar job of beating down the current system in the US, viewers are given selective glimpses of health care delivery in four countries: Canada, France, the UK, and Cuba. If we are to believe Moore, these other health care systems are specimens of finely-designed social policy in motion, offering free health care to all at no cost and no limit. This is where the film begins to falter for me.

Let’s start with this: When filming a documentary anywhere with a clearly visible camera and well-known filmmaker, the subjects would be idiots if they didn’t paint themselves in the best possible light. Moore uses that to his advantage, choosing archival footage to prove the brokenness of the American system and live footage of the four other systems. While he uses some live interviews to illustrate the inanity that is American health care, he carefully builds his case for why the system is broken with archival footage, including some eye-opening footage of a meeting between Nixon and Haldeman concerning Kaiser Permanente and the idea of private, for-profit health organizations. There is no question that his point is driven home with the combination of statistics and never-before-seen footage of a private Nixon-Haldeman meeting.

Moore was interviewed by Amy Goodman today.  This excerpt sums up his argument against our current system:

And these health insurance companies are — they’re just — they’re the Halliburtons of the health industry. I mean, they really — they get away with murder. They charge whatever they want. There’s no government control. And frankly, we will not really fix our system until we remove these private insurance companies.

On the candidates’ proposals for reform:

Kucinich is closest to the right idea, and, of course, he keeps, you know, saying “nonprofit,” or whatever. But I kind of don’t want to use that word anymore, and I wish that Dennis wouldn’t use that, because Kaiser Permanente is a nonprofit. Blue Cross is a nonprofit.

That’s why I say that essentially you don’t want any private insurance companies involved and that whether they’re for private or nonprofit, because — but when I say “profit,” you have these huge nonprofits that are under the guise of nonprofit, but they’re all about profit. They’re all about making money for themselves and for their executives, and what they make is obscene. And so, I favor the removal of all private insurance companies.

I agree with everything he says. It’s a sick joke to call these organizations “non-profit”. Of course they’re about profit. It’s just that the profit goes into the pockets of suppliers and managers and executives at the expense of patients and doctors. I argued in an earlier post that the reason the Pharmacy Benefit Managers remain for-profit corporations is to line the pockets of the executives who sit on the boards of the non-profit health insurance corporations. I haven’t seen anything to convince me to change my mind, and the statistics tell the story:

First Quarter Results for the Top 3 PBMs:

So Michael, now that we know it’s broken, how should it be fixed?

Moore takes us on a short, worldwide odyssey to look at four other systems in action. In each case, health care access is universal, unrestricted, does not appear to have the bureaucratic red tape of other systems, and delivers better end results.

As I watched, I kept asking myself the same two questions:

  1. How is it administered?
  2. How is it funded?

You will not have the answers to these questions at the end of the film.  So I went looking for my own, in Moore-esque fashion.  In each case, I tried to go either to the source itself or a respected organization.  Because I do not speak French, for example, I relied on the English-language reports of Civitas.org, which appeared to be an objective analysis of the French health care system. If there are flaws in these reports, please post a comment with suggestions for more objective reports that I can actually read.

Canada
WHO Core Statistics

In a comment to my initial post about this film, Stephen Downes challenged me to ask Canadians whether they’d trade their health care system for the one in the US. So I’m asking — Canadians, would you trade? And if not, why not? And beyond that, it would be great to read about what you like, what you don’t like and what you’d change about your current system, too, assuming you would keep it.

Health care benefits in Canada are paid for through a combination of taxes (public sources), supplemental insurance, out-of-pocket expenditures, and donations (private sources). According to the Canadian Institute for Health Information, the split of public/private expenditure in 2005 was 70% public, 30% private. However, the Canadian healthcare is struggling with rising drug expenditure costs, long wait times for some health services (See Wait times for treatment in Canada), and rising drug expenditures, which are rising at a nearly-exponential rate.

When Michael Moore was asked about these flaws in the Canadian system, he responded with this:

And, you know, you’ll hear the critics of the Canadian system here talk about, “Oh, the Canadians, you have to wait in line, you know, before you can get a knee replacement, or you have to wait x-number of number of weeks, you know, where you don’t have to wait in America.” You know, when I hear that, I think, well, that’s what you do when you have to share the pie. Sometimes you have to wait.

I agree — sometimes you have to wait. The problem is, there are some conditions that don’t wait. They worsen with time. But what Moore misses is this: Canada’s health care system is threatened by the same gremlins that haunt ours. The issues of cost containment and out-of-control pharmaceutical costs are global — they affect the Canadian system, the UK system, and the French system. These problems have not gone away, despite the universal access to health care offered by these other countries.

France
WHO Core Statistics

France has an amazingly complex system. The best illustration of its structure is this page, excerpted from the full Civitas.org report cited below. As close as I can tell, France employs a hybrid payer system which largely funded with public funds and supplemented to a small degree with private funds. France also has one of the top-rated health care systems in the world, yet this country is also grappling with similar questions on how to maintain excellence while containing rapidly rising costs.

From Civitas.org1:

The organizational structure of the French health care system makes this goal [cost containment] difficult to achieve. It is difficult to control expenditure in a system where the freedom of patients and providers is unrestricted, where care is largely publicly funded and retrospectively reimbursed and where health insurance funds have no real financial responsibility. Not surprisingly, therefore, the French health care system is relatively expensive by international standards, and the slowing down of expenditure growth which most countries achieved during the 1980s has only recently occurred in France, in the second half of the 1990s.

Although relatively high levels of expenditure on health care result in patient satisfaction and good health outcomes, cost containment remains a permanent subject of debate, since many of the measures taken to reduce expenditure growth have been ineffective and have always been strongly opposed by professional associations, particularly doctors’ associations.[emphasis mine]

and this, from the conclusions:

Finally, the financial sustainability of the health care system is a perpetual source of concern, particularly due to the fact that actual expenditure consistently exceeds the targets set. Until now, the high cost of the health care system has been accompanied by high levels of access to health care, but the demographic change expected within the health professions may lead to an increase in explicit rationing in future years.

Great Britain/NHS
NHS Core Statistics

Great Britain’s system is completely funded by public funds. It is widely regarded as one of the most accessible and patient-friendly systems in the world, and yet, reforms are being considered for this system as well.
From a 2005 NHS document2, a description of the NHS today:

  • the NHS has achieved a lot
  • there are both public and staff concerns
  • the NHS has been underfunded for decades
  • a 1940s system in a 21st century world

According to the report, decades of underfunding are now coming home to roost. Some of the reforms the NHS are weighing include: empowering patients, decentralizing services, more focus on wellness, preventive care and self-care, increased funding and yes, managing the cost of pharmaceuticals and facilities.

Wait time is also an issue in Great Britain, and the initiative seeks to implement procedures which will ultimately reduce the wait time and improve overall delivery of healthcare services.

Cuba

Cuba’s health care system is completely nationalized and controlled by the government. According to the Journal of the American Board of Family Medicine, Cuba’s health care system is “notable for achieving developed country health outcomes despite a developing country economy.”3  Despite the stark differences in economic models and per capita income, Cuba has health outcomes that rival those in the US for a fraction of the cost.

The central framework of the Cuban health care system rests on the family practice, an emphasis on wellness and disease prevention.  As Moore points out in Sicko, there is a clinic on nearly every block, with doctor or nurse who live in the community they serve.  Cuban physicians practice traditional and complementary medicine, and interface with the specialists serving those in their patient-community. 

Here is a comparison of the Cuban health care system to that of the United States:

Cuba has the highest family physician-to-population ratio in the world,11 and it has a family physician-per-patient ratio of approximately 1:600.8 In the United States, the average family physician-per-population ratio is approximately 1:3200.15 In 2001, only 35% of Cuban residency graduates specialized further (including 8% who graduated in general internal medicine and pediatrics).16 In the United States, only a third of physicians are primary care physicians (ie, family practice, internal medicine, and pediatrics physicians).17 Only 11% are family physicians.18

Other features of the Cuban health care system include holding physicans accountable for health care outcome measures in their community, evaluation of patients within the context of their family and community, and combining traditional pharmaceuticals with the complementary treatment methods by doctors trained in their use and implementation.

The conclusion to this report is one worth noting:

Despite political differences, Cuba and the United States share a passion for baseball and for family medicine as an important component of the health care system. At a structural level, the Cuban and US health systems differ drastically: Cuba provides universal health insurance and every physician completes a family medicine residency. In contrast, the United States has more than 46 million uninsured residents, and only 11% of its physicians practice family medicine.

So What?

Michael Moore gets more right than he does wrong with Sicko. He hasn’t convinced me that universal health care will work in this country without a radical takedown of some long-revered and powerful institutions. To accomplish any meaningful reform, Americans will have to dismantle the insurance and pharma lobbies at a minimum, and begin to tackle the question of how to deliver universal health care without tying it to employment, marital status, or other qualifiers (and figure out how to put all those unemployed pharma and insurance reps to work, too). Once those lobbies have been set aside, the questions of how to implement a healthcare system which avoids the pitfalls faced by Canada, the UK and France, embraces the positives in the Cuban system, and essentially folds a socialist system into a capitalist society will have to be addressed.

One thing is sure: This will not happen overnight. I do believe it can happen, but only if it’s done as part of the largest social, non-partisan debate we’ve ever had in our country about something which is truly universal. Health care may not be a right, but it is a fundamental need and without a method to deliver it effectively, we are dooming ourselves to a stunted economic outlook where the mega-rich become richer at the expense of public health. What cannot happen is the application of a political, band-aid solution that gives the appearance of reform but carries the stench of the profiteers underneath.

1Health Care Systems in Transition, 2004, Simone Sandier,Valérie Paris,Dominique Polton
2The NHS Plan: a plan for investment, a plan for reform
3Family Medicine in Cuba: Community-Oriented Primary Care and Complementary and Alternative Medicine

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Healthcare: Doctors Denying Benefits

March 25, 2007 · Posted in Domestic Policy · Comments Off 

Part II of a series on healthcare reforms

Adam J. Wolfberg wrote an excellent commentary for the Boston Globe today on “Hippocritical Doctors”. The issues he describes in his column go right to the heart of the issues at the heart of the PBM problem in my previous posts and deeper to the heart of the overall brokenness of our healthcare system.

Dr. Wolfberg’s daughter has cerebral palsy. The best treatment for her condition is physical therapy which was denied by his insurance by two separate doctors paid to review and deny claims. Describing his experience, he notes the following:

While one of these doctors has no expertise with cerebral palsy, the second one does. In his other job, he cares for children with severe physical disabilities and is a proponent of therapy for disabled children. As he wrote to me in an e-mail, “my personal view is that children with [cerebral palsy] benefit from therapy services.” However, in his review of my appeal, he wrote a careful explanation justifying why the health plan should not pay for the therapy.

So two doctors, one with NO expertise in the area of treating children with cerebral palsy, and one with extensive experience in the field and who holds the personal opinion that children benefit from physical therapy, are charged with saving the insurance company the cost of covering the therapy. Dr. Wolfberg definitely has an opinion about this:

This doctor and others like him are making money denying care – and they might as well hang up their white coats. They may believe that their administrative decisions are medically justifiable. However, it often appears that they are hired because their MD degrees lend a patina of legitimacy to administrative decisions that are based on interpretation of a health plan’s policies, not a chart, lab test, or CT scan.

This is the dark side of our healthcare system: There is only incentive to deny claims, not to evaluate them fairly and approve or deny based upon facts, expertise and the best interest of the patient. The ones who are harmed are the patients, with real conditions, some life-threatening, others not. Dr. Wolfberg concludes with this:

Individuals are harmed when medical care is withheld. Many of these health plan doctors, whose job it is to reject claims, end up being paid to violate the Hippocratic oath they took when they graduated from medical school – to “first, do no harm.”

That is the heart of the matter: There is an irreconcilable conflict when insurance companies place physicians, bound by oath to do no harm, in a position where their decisions are driven by the bottom line instead of the patient’s needs. The most qualified individual to determine a patient’s needs is their own PHYSICIAN. What we have here is a system where the decisions of treating physicians are disrespected in favor of an arms-length review and denial by colleagues who sold their white coat for a paycheck.

Anyone seeking a career as a doctor (particularly one in general practice) today would have to be certifiably insane.  Assuming they make it through medical school, their internship and residency, they come away with tremendous debt.  Then they are injected into a system where their decisions are second-guessed by insurance company physicians, their malpractice insurance costs equal more than they pay for their homes, their rates are dictated by arbitrary price-fixing and they have to navigate a maze of red tape and paperwork to see patients at all.

Contrast this with one person’s recent experience in an emergency room in France:

…there’s no paper needed anywhere, no forms, no signatures. The French have developed what I would call the USERNAME system of medicine. Just like many web sites who just want you as a user and don’t really care about your real identity, the French Emergency Health care system is the same. They would like to know who you are but they do not need to know who you are when you are in a medical emergency.

there’s absolutely no paperwork. I had never seen anything like that. You tell them your name, they believe you, you tell them your address, they believe you. They don´t ask you for medical insurance nor for any kind of payment and the whole admission takes at most 45 seconds.

the legal system is mainly absent from French medicine. When it was all done it was shocking for me to leave the hospital without having to sign any release forms. The surgeon herself notified the administrative staff that I was done and she released me simply saying that I could go home without seeing anybody.

This author concludes:

But what’s wrong with the American health experience is that it is invaded by a lot of elements that are foreign to medicine. The result is a cost so onerous that the percentage of GDP Americans spend on medicine is much higher than in France but the results are very disappointing.

Indeed.

(Hat tip to Kevin, MD for the link to Dr. Wolfberg’s article)

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Healthcare: Caremark Profits Rose 15% in 2006

March 25, 2007 · Posted in Domestic Policy · Comments Off 

An illustration of why PBMs are such wonderful cash cows for the insurance boys:

For the year ended Dec. 31, Caremark reported that its profit grew 15 percent to $1.07 billion compared with profit of $932 million in 2005. Caremark’s revenue grew 11 percent in 2006 to more than $36.7 billion from revenue of nearly $33 billion in 2005.

Keep in mind that Caremark was being courted by two suitors at the end of 2006: CVS and ExpressScripts. CVS won, just last week.

What those profits mean to the insureds: Denied claims and substandard claims review.

What those profits mean to employers: No reduction in the overall burden of providing pharmacy benefits.

What those profits mean to the healthcare system overall: Erosion of the quality and standard of care available to all insureds, and in particular, insureds who are covered by Medicare or Medicaid.

Did I mention that the CEO of Caremark’s predecessor (AdvancePCS), David Halbert is a good buddy of our esteemed President? Did I also mention that he was one of the key drafters of the current Medicare pharmacy benefit laws? Follow the money.

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Healthcare Reform: PBMs Don’t Save Money

March 24, 2007 · Posted in Domestic Policy · 5 Comments 

[First in a series on healthcare reform]

Those who read my personal blog know that I have a special place on my hit list for Pharmacy Benefit Managers, or PBMs. This stems from: a) My personal experiences and ongoing struggles to force Caremark to honor their contract and cover prescription ADHD medications which are necessary and which are prescribed by a qualified physician after the proper diagnosis was made, and b) My professional experience as a third-party pension administrator with more than 20 years time in the business and a better-than-average understanding of ERISA and employee benefit plans.

In our current healthcare system, PBMs are viewed as a cost-saving mechanism to deliver prescription medications to insureds under contracting health insurance plans. Let’s be clear:  They are an invention of the major insurance companies, who separated themselves from pharmacy benefits in order to continue to realize profits on one of their largest profit centers while becoming non-profit corporations.

In fact, PBMs create an additional layer of administrative costs while serving as a pathway to deny legitimate benefits to insureds while keeping the insurance companies’ involvement at arms-length. They are the unclothed emperor of the health insurance industry, but there are some who are calling them what they are.

Recently, I wrote that Caremark dodged a legal bullet when a Federal Appeals Court ruled that Caremark had no fiduciary liability for denying benefits to covered individuals, defining them as a contract administrator only. I disagree with this ruling for a number of reasons, despite the party line that the Caremark employee-commenters like to leave about how the insurance contract dictates the benefits, Caremark merely carries out the contractual arrangement and so on. The fact is that it is Caremark and Caremark employees, qualified or otherwise, which make the determination as to whether or not to deny access to a “prior authorization required” medication. I have copies of letters proving that, where a gastroenterologist who has not practiced for two years denied my access to ADHD medications.

Now it seems, the courts and state legislators are waking up to that fact. Over on the Health Plan Law blog, they report that PBMs just lost a significant decision, and that there is legislation pending to regulate PBMs in 36 States and the District of Columbia. They report:

Thus, state lawmakers are taking seriously the allegations of fraud and abuse by PBM’s and are doing something about it.

In this particular case, the courts continued to hold that PBMs are not fiduciaries under ERISA. (Note: That determination does not preclude them from being considered fiduciaries under a less restrictive standards. ERISA is one of the most restrictive definitions of fiduciary on the books). This particular aspect of the ruling went to the benefit of the PBM, since it stands to release them from any liability for arbitrary and capricious denial of benefits.

What was good about this particular ruling was the larger issue: State regulation of PBMs.  It paves the way for states to force transparency and disclosure, which is definitely a victory for insureds who are subject to their whimsical claims denials, as well as unbridled rebating practices and other methods of lining executives’ pockets.

In other litigation involving Caremark and Medicaid, it seems that Caremark was denying claims for Medicaid reimbursement, because the insureds were not presenting a Caremark card and therefore not compliant with the pharmacy benefit plans they administered. But here’s the catch: The insureds in the TennCare plan could not comply with the card presentation requirement because the agency responsible for Medicaid benefits did not have a card. Further, Medicaid is the final payor if there is other coverage present. In other words, all other avenues for payment have to be exhausted before Medicaid will make a claim for benefits. When TennCare would file with Caremark for reimbursement, they were denied on the basis of not presenting a card and not filing a timely claim.

Caremark effectively constructed a Catch-22 that insureds could not navigate their way through:  They created compliance requirements that the insureds could not meet.

The court ruled that the requirements were discriminatory against Medicaid; however, Caremark has still weaseled away from any liability by passing it through to the insurance company it serves. If Caremark has the power to deny payment of benefits and is subsequently found to be liable for those benefits, the cost for the benefits pass through to the insurance company.

All of this leads back to this question:  What good is the PBM?

The answer: Not much. On the Health Plan Law Blog again, an excellent analysis of the utility (or non-utility) of the current PBM structure.

PBM’s promise to deliver cost savings to health plans through plan design, effective purchases of appropriate pharmaceuticals, disease management and various ancillary services. The PBM’s dictate the formularies that drive traffic toward certain drugs and away from others based on reimbursements that the PBM’s specify. Inasmuch as the big are posed to get even bigger, these current events present an occasion to reflect on the utility and effect of the PBM mechanism in the American health care system.

The entire post should be required reading for anyone interested in our current healthcare delivery system and the corrupt structure of the PBMs. It points out that the use of rebates is rarely passed through to the consumer, though the price for acquisition of prescription medications is increased in the United states by 50-70%, mail order savings are not passed through to the consumer, there is non-transparency of price fixing on generic medications, bloated costs associated with an additional layer of administration, and the liability for claims denial skips the PBM and lands at the feet of the employer and insurer anyway. Those factors say to me that the answer to whether PBMs help or hurt the healthcare system is clearly “NO”.

If we are to have any hope of arriving at meaningful healthcare reform, it’s going to be necessary to shed the idea that there are sacred cows which cannot be sacrificed. There isn’t much dispute that the current system is broken, and rather than putting a bandaid on it, we’d do better to look hard at each piece of the current system and make a decision about whether it should remain in a reformed system. I do not believe there is a place for PBMs in the reformed system. Claims management for pharmaceuticals should follow a standardized procedure that encompasses all claims, with no special carve-out for pharmacy benefits. I would be much more supportive of a system that applied fair and non-discriminatory standards to prescription drug coverage than the arbitrary, capricious, and profit-taking system we have now.

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For want of $80, a life is lost

March 3, 2007 · Posted in Domestic Policy · Comments Off 

For lack of a shoe, the horse is lost…

Abcessed teeth can kill you — the infection can spread until it ultimately infects the brain, which is exactly what happened to Diamonte Driver, a 12-year old child whose mother had no insurance and couldn’t find a dentist to treat her son.

It’s outrageous that such a thing can happen in this country, but thinking beyond the outrage for a minute, this is a shining example of WHY some form of healthcare is so essential to the economic health of our country. Consider what the expense of NOT covering an infected tooth cost: More than $250,000 for two surgeries and over six weeks of hospital care, all administered much, much too late.

Over the next month, I’ll be writing in depth about healthcare, healthcare policy as it stands today and as it’s been proposed for the future. I have no answers, just lots of questions, but if we don’t really start considering the details rationally and without partisan bias, there will be more Deamonte Driver tragedies that are so preventable, yet still happening.

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