The hidden prescription drug battle: When seeking much needed medication, are you dead on arrival?

An increasingly influential nonprofit is undercutting medical innovation and building barriers to access between patients and their medicines – all under the guise of a cost-cutting scheme that puts the sickest among us on the chopping block.

While lawmakers and reporters hold their magnifying glass up to the pharmaceutical industry, corporate insurers and the pharmacy industry have skirted public scrutiny and used research from a nonprofit, the Institute for Clinical and Economic Research (ICER), to help them deny patients higher cost-medications, even if they need and deserve them.

ICER provides analysis that effectively functions as a price control on medicine. It targets a disease, writes a report to inform health insurers on the supposed cost-effectiveness of a drug and then insurers can decide whether or not to use that recommendation.

It does this through mathematical calculations known as “value frameworks” to justify the nonprofit’s preference to target certain drugs. But this is no unbiased test or dispassionate statistical measurement. It’s a Catch-22 in which patients can’t win because the ICER process determines they have a lesser quality of life than a healthy person – forever. 

Seen this way, ICER’s pretzel logic gets straight to the point: Less human value should mean less human investment.

Everyone knows someone in need of daily medication for an ailment or disease. The expenses involved can be extremely high. But what twisted economic theory justifies the denial of life-saving cures because a sick person is deemed as too expensive to treat?

As Robert Goldberg, co-founder of Center for Medicine in the Public Interest told me: “You know what’s expensive to the health care system? People not getting medicines that can make them better, leading to far costlier surgery, rehabilitation and lengthy hospital stays.”

Medicare is now considering a policy that could restrict seniors’ access to cancer treatments and other physician-administered drugs based on ICER reviews. Insurance companies like United Health and pharmacies like CVS are working overtime to remove some medications from their formularies and coverage tiers or require patients to get sicker using less expensive drugs before they can receive cutting-edge therapies prescribed by their doctor. 

This is called “step therapy” – the idea that patients should “step” up to different levels of medication. Interesting theory, but in practice it means patients must “fail first” on medicines their insurance company prefers before being allowed to access the therapies prescribed by their doctor.

Exposed to the light of day, however, these anti-patient policies can be reversed.

This year, Attorney General Eric Schneiderman sued Capital District Physician’s Health Plan (CDPHP) for unlawfully restricting medical access for patients with chronic hepatitis, even though the drugs were shown to effectively treat – and in many cases, cure – the disease.

The AG said CDPHP denied coverage unless patients demonstrated an “advanced” state of the disease, including moderate to severe liver scarring. Two weeks later, several other insurers altered more policies to cover treatment for chronic hepatitis C. This is a clear win for patients, but we shouldn’t need AGs in every state to file lawsuits to stop these kinds of policies.

Where did insurance companies get the idea to cut off these patients? Maybe it was from Sarah Emond, ICER’s Chief Operating Officer. She told a New York gathering earlier this year: “If we pay for Hep C drugs then we will have to lay off teachers and close schools.”

Something has gone terribly wrong in our national conception of patients and their place in a health care system that increasingly sees them as a commoditized drain on resources, not individuals in need of care that can help them.

By all means, let’s put all these issues on the table. But denying patients as a way of saving money? That’s one idea that should be dead on arrival. 

 

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