The managed care wars of the 1990s, when patients complained that health plans would not pay for them to see the doctor of their choice, seem almost quaint in light of today's battles. With the rise of narrow networks, there are new fights about access to doctors, of course. But the more troublesome battles, which are sometimes literally life-threatening, involve access to drugs.
The managed care wars of the 1990s, when patients complained that health plans would not pay for them to see the doctor of their choice, seem almost quaint in light of today’s battles.
With the rise of narrow networks, there are new fights about access to doctors, of course. But the more troublesome battles, which are sometimes literally life-threatening, involve access to drugs.
Yesterday’s news of an anti-trust investigation, and reports of new, “non-preferred” tiers for generic drugs, all point to health plans and pharmacy benefits managers seeking work-arounds to the mandate of the Affordable Care Act (ACA) that consumers have access to coverage, regardless of pre-existing conditions.
For patients who have suffered for years with diabetes, HIV, hepatitis C, and other chronic conditions, the ACA promised a lifeline to treatment after years of impossibly price care or no insurance at all. But as many discovered, the world of managed care said, “Not so fast.”
Among the developments:
Prices for newly approved specialty drugs to treat cancer, hepatitis C, and rheumatoid arthritis have grabbed plenty of headlines—and plenty of pushback from health plans. But the quiet rise in the cost of generic drugs has only recently gained notice. As the Journal reported, last month Congress asked 14 generic drug manufacturers to provide data on why prices are rising so quickly.
As numerous studies have noted, price is both a consumer and a health issue, since patient out-of-pocket costs are directly tied to adherence. When patients cannot afford medications, some number of them will go without; as Oster and Fendrick noted, this will create costs and consequences elsewhere, and is unfair to hospitals and physicians who are now being reimbursed based on their patients’ healthcare measurements and readmission rates.
“Without choice, such policies are simply punitive and run counter to established principles of formulary design and management,” the authors wrote. “They also may increase utilization and costs elsewhere in the healthcare system, and ultimately may undermine emerging payment reform initiatives designed to reward physicians for attaining disease-specific performance metrics.”
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