At a time when prescription drug prices and spending are remarkably stable, patients are getting hit harder than ever by flawed policies and poor decisions by some within the health care system.
In case you missed it, a Texas high school teacher named Drew Calver suffered from a heart attack back in 2017. Calver’s neighbor rushed him to the nearest hospital where he underwent routine procedures to clear his blocked artery. After spending four days at the facility, Drew was discharged only to learn that the hospital was out-of-network – despite being told the opposite – and that his bill was $164,941.
“They’re going to give me another heart attack stressing over this bill,” Calver said. “I can’t pay this bill on my teacher salary, and I don’t want this to go to a debt collector.”
Another story featured 34-year-old Scott Kohan who ended up in the emergency room after he was violently attacked. This time, the hospital was in-network – but the doctor was not, resulting in a medical bill of $7,924.
“I went to a hospital where I am covered, and did everything I reasonably could do to confirm that I was going to be covered before having surgery,” Kohan wrote in an appeal to his insurance company. “Unfortunately, it didn’t work out the way.”
Fortunately, the stories end well for Calver and Kohan. Kohan’s doctor dropped the entire $7,924 charge after learning of his situation, and after the media ran their story about Calver, the hospital reduced his bill to $782.29. But not everyone is as lucky, and recent data proves that these two incidents are far from isolated.
A new survey out of the University of Chicago shows 57% of American adults have been hit with a medical bill that they expected to be covered by insurance. And when asked who was most accountable for these surprise bills, the overwhelming majority said hospitals and insurers. Even, Kaiser Health News is out similar poll results showing that when Americans think about health care costs, unexpected medical bills top their list of concerns.
New Regulatory Barriers to Needed Medicines
Medicare Part D and Part B have been a tremendous success for both seniors and taxpayers. However, new policies announced without the opportunity for public review and comment will leave patients with fewer choices, or hefty out-of-pocket costs if they choose to follow their doctors order. These policies, which include indication-based pricing and step therapy, are penny wise and pound foolish at best – and organizations representing both physicians and patients have been raising concerns with these recent proposals.
The American Medical Association noted: “Rather than benefiting patients, the CMS proposal actually introduces unfair complexity to Medicare patients and further cements the role that insurance companies play in deciding treatment plans. This is not a recipe for good health.”
The Arthritis Foundation stated: “[The] guidance from CMS to permit indication-based drug coverage in Medicare Part D represents a step backward from the program’s promise to these beneficiaries. … Allowing plans to limit formulary coverage of a drug only for the specific indication for which it is most effective will further restrict the already narrow treatment options available to patients with inflammatory forms of arthritis.”
The Community Oncology Alliance added: “Step therapy requirements are driven by financial interests to save money and not by what is in the best medical interest of patients. They leave patients at the whim of middlemen who are more concerned with their bottom lines than patient outcomes, side effects, and well-being.”
‘Cost-Effectiveness’ Measures Not What They Seem
The future of biomedical innovation is bright. Cutting-edge technologies like CRISPR have arrived, and new medicines to fight cancer and other debilitating diseases are on the horizon, but to be effective, patients must be able to access them. That’s why properly assessing the value of these innovative medicines, and the benefit they offer patients, the health care system and society more broadly is so vitally important.
Assessing the value of medicines is nothing new, but one approach that has garnered greater attention in recent years—an approach developed by the Institute for Clinical and Economic Review (ICER) — lacks transparency and sufficient input from the full spectrum of health care stakeholders. It’s also worth noting ICER’s past ties to the insurance industry, which makes us question who will ultimately benefit from their work that helps influence patient access to needed care.
Recently, CVS Caremark announced that it would adopt ICER’s arbitrary approach to measuring value directly into their coverage decisions. Such a move would provide a pathway for plan sponsors to incorporate the groups flawed process in determining when patients would have access to certain medicines. Former Rep. Tony Coelho (D-Calif.), who authored the Americans with Disabilities Act and now leads the Partnership to Improve Patient Care (PIPC) recently raised the red flag, arguing that this “type of cost effectiveness analysis discriminates against people with disabilities and other vulnerable groups like the elderly because it assigns higher value to people in ‘perfect health’ than people in less-than-perfect health.”
For a better approach, BIO joins PIPC and other health care stakeholders in supporting the Innovation and Value Initiative (IVI), which recently introduced its Open-Source Value Project. This transparent and holistic approach allows for a broad range of perspectives, incorporates the latest available evidence, and considers the full value of cures and treatments when estimating the value of medical technologies.
To make health care accessible and affordable for individuals across the nation, we must adopt market-based policies that put patients first. Individuals should not have to choose between sending their children to college or paying a hospital bill that their insurance company decided not to cover.