You may have already read this article in the NY times about “tier 4″ medications and how insurance companies plan to raise the costs to patients into the stratosphere. It made me sick. This just goes against the idea of insurance in the first place – to distribute the costs of care amongst healthy and sick so the sick don’t pay very much (well, premiums are high enough but this is above that).I mean, if you had to pay a percent of your cost for a totalled car (like 30% ) of a brand new 40,000$ BMW, you would vomit! How bout 30% of the price of your home if it burnt down! The whole point is that you pay your 250$ or 500$ deductible because the cost of your claim if offset by tons of people who did not have an accident or have a house fire.
The sickening thing about it to me is that the “tier 4″ medications are those that treat some serious (and actually not all that uncommon) chronic medical problems whose development most often has NOTHING to do with patients’ habits (like coronary artery disease and smoking or diabetes and obesity). Diseases like MS, forms of anaemia, leukaemia, and Rheumatoid Arthritis are often auto immune in origin and their development is terrible bad luck. No one smokes or drinks themselves into multiple sclerosis (at least not that we know of).
Plans that have this system are being offered to employers at cut rates (because they are shifting the costs to the chronically ill) and given the rising cost to insure one’s employees, I have no doubt these plans will become more popular.
I foresee patients rioting. I see them writing their congressmen/women. I see people calling lawyers. I see advocacy groups simply not tolerating it. I see insurance companies backing down (eventually after many people are either riddled with untreated disease and/or bankrupted).
Sigh.
Perhaps a better metaphor is a car insurance pool where 10% of the individuals own $150,000 Bentleys and 90% of the individuals own $15,000 Honda Civics. When accidents happen, it will cost more to fix a totaled Bentley than a totaled Honda, so the lion’s share of the resource pool is to pay for the Bentley repairs. What happens when the Honda Civic owners need repairs on their cars? Too bad, all of the insurance money was already spent repairing the Bentleys, so the Civic owners (90 percent of the pool) are out of luck.
That is, after all, assuming that there are no risk-adjusted premiums. When there is no risk-adjustment, all sorts of problems occur, such as denial of coverage because the pool is already spent on high-cost individuals. The insurer would then be forced to ration the care that it provides, and only a small percentage of the insured (maybe 10%) get benefits to the expense of all others in the pool. Is that fair to the other individuals?
Risk-adjusted premiums are critical to solving this kind of insurance problem. Either that, or high coinsurance rates are needed. Is it more palatable for RA-sufferers to pay $10,000 per month in a risk-adjusted premium rate for all inclusive coverage, or is it more palatable for RA-sufferers to pay 20% coinsurance rates with standard monthly premiums despite preexisting conditions? I would prefer the former situation (which happens to be my current insurance plan).
From a strictly economic point of view, the new plan structure makes sense. From a patient’s point of view, or a treating-physician point of view, this is absolutely tragic. Very sadly, the economics of health insurance are so dismal lately that we have been reduced to high coinsurance on Tier 4 drugs which will likely cause many people to suffer with diseases and die premature deaths. Really a sad state we’re in now.
What next? Seems like this is going to be bad for all of us!
unfortunately, the people won’t riot. if they haven’t found a reason to in the last 8 years, they certainly won’t over this. they’ll just lie down and take it like they take everything else.
I see a lot more people dying because they can’t afford the medications they need, but THAT will help the ins. cos. too! No more chronically ill expensive to treat people on their rolls.
Bear in mind, this is the ONLY major country that does not regulate and negotiate drug prices. Why is that?
Oh well. More $$$ to pay their CEOs and their people to deny claims.
The whole concept of insurance is not patient-friendly. Insurance was never meant to be what it is now. It was originally meant to underwrite sunken and hijacked ships coming out of Europe. Then, Baylor Hospital struck a deal with teachers to provide hospital coverage for a pre-defined amount…and our current healthcare system was born.
Insurance, from a business perspective, is about transferring risk from the patient to the insurance company. MCOs and capitation is about shifting the risk from the insurance company to the physicians. The insurance world, especially for-profit insurance companies, is not about looking out for the best interest of the patient. It’s about the bottom line. What is the economic advantage for an insurance company to provide care for patient with a serious chronic disease?
I agree that it’s a bad system. Any policy changes by insurance companies will not benefit patients or physicians. The only solution for fixing our healthcare system is the most politically unfavorable one – a single payer system.
To Gaile:
Plenty of patients, especially MS patients, have been raising a ruckus, but nobody seems to be listening. And certainly, those patients who are lucky don’t want to lose what they have and thus shove their heads in the sand.
Personally, I have MS and RA. I have non-group insurance with $25 doctors visit co-pays and 10% coinsurance payments. I have prescription coverage up to $1500 each year. Thus, my MS and RA meds cost me 100%.