Healthcare "Formularies": The REAL Obstacle to Reasonable Care

The Affordable Care Act (ACA) has gone into effect as of January 1, 2014. It is a private/public sector alternative to publicly funded Single Payer Universal Healthcare, and it was passed into law amidst a fury of debate and partisanship. The United States is one of the few western democracies that does not have a healthcare system that is funded in majority by public funding. The assessment of the availability of services does not bode well for people living in the United States, as the system lacks the base level of service standardization that exists in most of the other nations where "universal healthcare" is the law.

Even so, the harshest critics of the law (of which I am one), must acknowledge that the law has provided some basic types of healthcare coverage to a number of groups that did not have them before. One of the biggest boons provided by the law is the expansion of the government subsidized "Medicaid" program in states where the governors have agreed to cooperate in such an expansion. As of the full implementation of the ACA, only 25 states and the District of Colombia have expanded the Medicaid programs per the ACA.

While the law has already expanded the number of people with access to health coverage, there are disputes as to how many newly insured Americans this law has created. Estimates run in the millions, but actual numbers are still little more than estimates, since it is taking time for each state to establish both accounting and reporting procedures. However, no matter which sets of estimates are employed, it is clear that the number of people who now have access to insurance has increased.

Stepping away from the ACA and its various associated debates, there is one major part of healthcare that was not at all addressed by the law: Health Plan Formularies. These "formularies" are essentially lists of drugs and procedures that are considered standard treatment for specific conditions, and which the health plan will pay for without dispute. While there are supposedly "review boards" that establish them, much of what they represent is based as much on actuarial science as what might be considered "best medical practices." There is actually little information on the subject available to the public from such health plans, and the relevant government regulatory agencies do not seem the least bit interested in establishing any baseline standards, let alone regulations, on how they should be established and implemented. The American Medical Association established a set of recommendations that seem to have largely been ignored.

The net impact of these "formularies" is to make the practice of medicine a nightmare for most healthcare providers, such as doctors, therapists, and other who would prescribe medicines and procedures that might not be part of a health plan's "formulary." Aside from the numbers which the plans provide themselves, there does not seem to be any entity looking at the actual number of prescriptions issued by licensed health care providers that are denied by health plans because they are "non-formulary" items or procedures. If you judge by the anecdotal information found on discussion boards frequented by both providers and patients, the numbers appear to be quite high. There is no shortage of angry complaints by both providers and patients alike about having access to drugs and procedures denied with great regularity.

At this point in the implementation of the ACA, we are not seeing much movement on this issue. Patients are being forced to accept treatments based more on cost savings than on medical best practices. While there were critics of the ACA positing that the law would put the"government between the patient and doctor," what we see now is a health care plan dictating the drugs and procedures that doctors need to employ. There are no "death panels," unless you consider the idea that stockholder return on investment and "bottom line" are now as important as patient outcomes.

We appear to have lost track of what the hierarchy of fiduciary responsibilities are in this nation. Contrary to what is touted by numerous CEOs, their primary responsibility is not to stockholders, but to consumers paying for their products and services. Profits come after provision of products and services, not before. The cost of doing business must be considered as an immutable responsibility of the business entity regardless of what nonsense these misguided CEOs suggest. When one fails to provide contracted goods and services, that is called a breach of contract, and civil and/or legal action may be possible. We hear these misguided claims that companies exist to maximize profit as part of a confused propaganda drive to remove even the most basic responsibilities from large business entities. It is not appropriate to simply assume that these business entities are ready to act in the most ethical and responsible manner, there should be measures in place to require it.

What is happening to patients is that their treatment is being directly impeded by policies that are not in their best interests. And worse, no one in our government or in the health care plans appear to be the least bit concerned. These "formularies" are not democratically established, and since there is now a mandate to either have health coverage or pay a penalty, it seems that our government has an obligation to ensure that they meet standards of reasonableness in their establishment and implementation. Where is the political leadership on this issue? Who is acting as a voice for consumers who are clearly dissatisfied with the lack of access to needed medications and procedures not included on health plan formularies? Since when are company profits more important than human life?

I am calling on anyone and everyone who reads this, and who has experienced the denial of a needed medication or procedure to contact either their congress member, and/or senator and demand that they address this issue as soon as possible. If the ACA is to be a vehicle for improving access to health care for the majority of Americans, the consumers of health plan products and services need to have access to the best their health care providers can give. And it should be the responsibility of the health plan to demonstrate that a prescribed medication or procedure is being prescribed frivolously by the licensed health care provider, with the consumers medical records in front of them, and with a medical (not financial) rationale for denying the medication or procedure. Denying medications and procedures on the basis of charted information is not only inhumane, it represents a breach of the health plan's fiduciary responsibility. And, it is time that our politicians stepped up and did something to even out the process so that consumers are provided with health care based on their best interests, not solely the P & L sheet of the health plan.