According to a 2021 study, 1.1 million deaths—including one in two of those under 65, thanks in large part to our abysmal health care system—”would have been averted if the U.S. had the mortality rates of other wealthy nations. One in three GoFundMe campaigns is now for healthcare-related costs, and it’s getting worse.
The passage of the Inflation Control bill is an excellent first step in limiting high drug costs, but our healthcare system is still built for profit at the expense of patients.
First, the health insurance companies are making a lot of money while burying doctors in paperwork and limiting treatment options. The insurance companies get to dictate medical care and go out of their way to deny medications, surgery, or treatments with no repercussions. They also require crazy hoops of prior authorizations for practices to send in. Patients and doctors are tired, and insurance companies are raising rates after two years of making a surplus because nobody went to the doctor during the pandemic.
Prior authorization is out of control. “Once limited to a few new treatments, it’s now being applied widely, even to generic drugs and established regimens. The result: delayed, denied, and abandoned care.Gerald E. Harmon, MD, Immediate Past President of the American Medical Association, in an Aug. 3, 2022, email to U.S. doctors.
Keep in mind that United Health Group’s revenue grew by 11.8 percent in 2021, climbing to $287.6 billion. Andrew Witty, its CEO, had a 2021 pay package worth $18.4 million while they get to dictate medical care and go out of their way to deny medications, surgery, or treatments. It also affects the industry as a whole.
A new study finds that nearly nine in ten doctors believe barriers set by insurance plans have worsened conditions for patients needing care.
Researchers with Aimed Alliance, a non-profit that seeks to protect and enhance the rights of health care consumers and providers, say that doctors are so fed up with the constant headaches caused by insurers that two-thirds would recommend against pursuing a career in medicine. Nearly half (48%) are considering a career change altogether.
Researchers found that physicians don’t think very highly of health insurance companies and believe they’re putting patients at risk with policies such as prior authorizations ahead of filling prescriptions. 87% of doctors say patients’ conditions have worsened because of red-tape regulations, and 83% worry the patients will suffer prolonged pain.
Prior authorizations are especially bothersome for doctors. More than nine in ten (91%) of those surveyed think the policy delays necessary care for patients. Similarly, the same number of doctors agree insurers engage in “non-medical switching,” which forces patients to take less costly — but potentially less effective — medicines.Aimed Alliance, a non-profit that seeks to protect and enhance the rights of health care consumers
Health insurance policies are stressing many physicians out. Thirty-seven percent say insurance issues cause half or more of their daily stress, and 65% feel they face more significant legal risks because of decisions made by insurers. The vast majority (85%) are left frustrated by such issues, and many admit to taking their anger and emotions out on their staff and even family members.
The survey showed that 77% of doctors have had to hire more staffers to handle the heavier administrative load from insurance work. Ninety percent said they have less time to spend with patients because of the burden.
As for the aspect of insurers’ policies that doctors would like to see changed most, the majority (55%) agreed on an insurer’s ability to override the professional judgment of physicians. About nine out of ten (87%) respondents felt that insurer personnel interfere with their ability to provide individualized treatments for each patient.
What about the new bill to help Medicare patients?
Pricing for prescription drugs is about as transparent as airline fares. What you pay depends on your drug plan, whether your medication is subject to a deductible, the price tier or level it’s assigned by your plan, how much you have already spent on drugs during a given year, where you buy them, and — in the case of brand-name drugs — the whims of the pharma, PBM and insurance companies.
Medicare drug insurance is a product of compromise after decades of debate in Congress. The government sets the ground rules for drug coverage through stand-alone Part D plans or benefits embedded in Medicare Advantage plans. This year the government is projected to spend $111 billion on Part D benefits. Currently, the government is forbidden to negotiate drug prices; the Inflation Reduction Act proposed by Senate Majority Leader Charles E. Schumer (D-N.Y.) and Sen. Joe Manchin III (D-W.Va.) would permit Medicare to negotiate the prices of 10 drugs, scaling up to 20 by 2029. Additionally, the act would cap out-of-pocket drug spending under Medicare at $2,000.
Part D plans differ in premiums, deductibles, co-pays, formularies, tiers, and preferred pharmacies. If you take no drugs, your decision is easy: Take the plan with the lowest premium. Otherwise, you must rely on a comparison tool on the Medicare.gov site. You input the names of the drugs you take, and the calculator ranks plans based on total cost — that is, premiums plus co-pays — for the remainder of the year. Higher premiums do not necessarily correlate with lower co-pays.
Everyone has different pharmaceutical needs. In many cases, one drug may drive your decision — typically a brand name or a high-tier generic that only a few plans cover effectively. In effect, the Part D system slices the market into as many groups of consumers as there are plans. Insurance is supposed to spread risk over as large a population as possible. Not our system. People who are healthy win; people who are less so lose, sometimes significant.
Generic drugs may also be cheaper with a coupon than your drug insurance. You can comparison shop on websites such as GoodRx.com and SingleCare.com. Imagine if Medicare, like most employer insurance plans, offered a single drug plan. Costs would be spread over a risk pool of 65 million enrollees rather than divvied up among more than 750 Part D plans nationwide and scores more Medicare Advantage plans. An 85-year-old grandmother would not have to worry each fall about changing plans. A 70-year-old father diagnosed with diabetes in June would not face the prospect of super-high costs until he is eligible to select a new plan. No one would worry about which pharmacy is in or out of network.
We have a long way to go to get to a healthcare system that puts patients first, but right now, it’s just too profitable for healthcare companies.