Next President Must Address Insurer Interference in Health Decisions

It’s that time in the political election season, where opinion polls get watched moment by moment like the NASDAQ stock ticker, going up and down with everyone trying to figure out what numbers we’ll see tomorrow. Important to be sure, but after Election day, it’s only a matter for the history books.

Some opinion surveys, however, matter right now – and potentially even more after the White House’s next resident moves in.

A recently released study by The Partnership to Fight Chronic Disease (PFCD), reports 77 percent of Americans said they or someone they know had trouble using their health insurance in the past year. A full 43 percent say costs have increased.

The survey findings get worse. Half say the treatment their doctor recommended was not covered by insurance. And another 50% say they were actually unable to fill a prescription at the pharmacy because the out-of-pocket costs were too high. Plus, virtually the same amount of people claim they had trouble getting insurer approval for a needed treatment or service.

If you have higher costs, restricted access and no more doctor-patient relationship, do you really have insurance anymore?

You would need to be living completely off the grid to miss the fact that we are in the midst of a prescription drug war and patients are losing the proverbial battle. Many would have you believe this is due to high drug prices, but that argument is an illusory way of concealing the truth.

In actuality, the real fight is for access to critical medications.

Every day, insurers assume the role of judge, jury and medical expert, denying medications that real doctors deem medically necessary. Their motivation – whenever a health insurer denies the more expensive medication in favor of a less expensive, (often less effective) medication, they are hoping you will forgo the fight and agree to submit to their decision. To be sure, their motivation isn’t sicker patients, but that is too often the obvious result when insurers compel the use of the medication of their choice and not that of your doctor. To add to the problem, most patients go along to get along. Do they really need another battle when they’re fighting for their lives?

We no longer live in the world where patients can believe they are mostly or only in the hands of their doctor. More accurately, their fate lies in the acuity of insurance bureaucrats who increasingly shape and form the treatment decisions of your doctor.

It should be mentioned that this can sometimes result in proper consensus. But as institutional policy, it shifts the balance of power from medical experts to health bureaucrats. If you need that medication, maybe too bad for you. The premiums you’ve been paying and the policy in your pocket are hardly the final word.

What the PFCD has uncovered is the hidden enigma that health insurance has become for many patients experiencing fear and loathing at the pharmacy while trying to gain approvals for much-needed treatments and procedures recommended by their doctors.

So where do we go from here? And what should patients, advocates, providers and doctors do? We say get back to basics. Advocates and patients need to stand up for their rights. Doctors and providers should facilitate medications and therapies deemed medically necessary by doctors, not by insurers.

At its core, health care is made up of a patient, a doctor and a plan for treatment. Of course there’s a lot more ultimately involved, and that’s a good thing. But we’ve moved too far from the fundamentals and it is time to ask some difficult questions.

Who or what is to blame if a patient is denied a medicine by their insurer and gets sicker? Or worse than that? Is it the mathematical formula used to deny prescriptions that don’t fit a cost-benefit analysis? Are patients a commoditized drain on resources? Or human beings we commit to helping?

Finally: If doctors are required to take an oath and expected to uphold ethical standards – is it time for insurance officials who override these medical decisions to stand up, raise their right hand and similarly swear to do no harm?

One more audience to think about. According to the PFCD poll, respondents said the top health care priority for government officials should be managing premium increases, lowering co-pays and deductibles and holding insurance companies accountable.

Sounds like an agenda even for the next president as well.

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