Health Insurers and Step Therapy

[Mama_Zappa]

@JcWoman

Now that you mention this, it is rather fascinating. There’s been a lot of pressure on the insurance companies to stop paying high prices for things like drugs. So they implemented the pharmacy management plans/companies that I referenced earlier. The fascinating thing is that this has utterly failed to bring downward pressure on drug prices. Even when people die and the media gets a hold of it like the poor diabetic man who died recently because he couldn’t get insulin… even THAT doesn’t seem to be stopping the drug price inflation.

PBMs don’t try to save the consumer (or the insurer) money.

They push the medications that give the biggest rebate. These rebates are not always passed on to the insurers, either.

John Arnold: Are pharmacy benefit managers the good guys or bad guys of drug...

Pharmacy benefit management

All in all, it’s a scam that helps to obfuscate the true cost of medications.

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[Max_S]

@Mama_Zappa

One problem, though, is that the formulary can change quite arbitrarily.

It doesn’t make sense, and is often annoying. Still, and this is legally important but usually impractical, you can pay for the drug yourself, and the doctor can prescribe whatever he or she thinks is appropriate. Your insurance company only controls what they will pay for. They can say “we aren’t paying for Flovent any more” but they can’t stop the doctor from writing “Flovent” on the prescription pad. I think Flovent is $250-$300 a pop, and if you front the money, your drug plan will sit back and say “good for you”. In practice, people can afford their health insurance, not health insurance plus the full price of prescription drugs.

~Max

[Max_S]

@bump

The part that really stuns me, as a business school grad, is that the companies are going about this so blatantly. I mean, they could have basically done the price increases boiling-frog style at increases of $2-5 (or some other nominal amount) at a time over a period of time, and probably not attracted much attention.

But no, they somehow got the idea that it was a good idea to just jack up the prices in one fell swoop. It’s like they didn’t do any of their analyses that would have indicated that a bunch of negative media attention and public backlash might actually end up causing some sort of regulation on this sort of thing.

Two words: inelastic demand. Drug manufacturers don’t care because they don’t have to care. People will die without their drugs. You cannot boycott life-saving medications. Often enough, patents, insurance contracting, market forces, and simple biology will lock a patient in to a particular brand of medicine. These companies have only two sources of downward pressure: government regulation and the natural limit of how much people are willing to pay before they literally give up and die.

As it so happens, the government has a strong interest in making sure this second option is never exercised, and so it subsidizes a big chunk of prescription drugs. This leaves only one downward pressure, which is government regulation. It is no wonder that drug companies spend so much on lobbying, or that they are so successful in doing so.

~Max

[Mama_Zappa]

@Max_S

It doesn’t make sense, and is often annoying. Still, and this is legally important but usually impractical, you can pay for the drug yourself, and the doctor can prescribe whatever he or she thinks is appropriate. Your insurance company only controls what they will pay for. They can say “we aren’t paying for Flovent any more” but they can’t stop the doctor from writing “Flovent” on the prescription pad. I think Flovent is $250-$300 a pop, and if you front the money, your drug plan will sit back and say “good for you”. In practice, people can afford their health insurance, not health insurance plus the full price of prescription drugs.

~Max

Yep.

There’s usually an appeals process, if you can prove you tried the alternatives and they didn’t work for whatever reason, but that can lead to delays. In my case if this happened again, I could argue that one switch caused problems in the past, but they might still argue.

I’m on a proton pump inhibitor - one of the newest ones on the market. Doc put me on that after it was clear an older version wasn’t doing the job. He sent a letter to the insurer - and all was fine. This, I think, is a good example of the step process working as it should.

I use Metformin - the extended release version. Doc wanted to raise the dosage from 500 to 1,000 mg a day. 500 mg a day is very, very cheap. The 1,000 mg tablet was not covered - and if I could get it covered under appeal. it would have been CONSIDERABLY more expensive. It wasn’t even a brand name, as I recall. Between Dropped-em not getting paperwork to the doctor, and/or the doctor not receiving the paperwork. and/or the doctor not returning the paperwork to Dropped-em, it was a full month before the appeal got filed and ultimately approved. Of course the doctor’s office is partly culpable here too: I kept leaving messages saying “Well, why not just prescribe TWO 500MG TABLETS A DAY”, and they kept not responding to that. They finally did - and that’s what I use. Hella cheaper than the exact dosage in a single tablet.