Why It Behooves All of Us To Not Stake Our Health On 3rd Parties
Your life or death decision often comes down to one person who sits at a desk at your medical insurance company. How is that fair?
Medicine and medical insurance are businesses. We often don’t want to admit this to ourselves, but it’s true. I’ve always had a mild hesitation when it comes to any type of insurance whether it’s home, life, auto, you name it. Think about it. Every month, you pay money out of pocket to protect your life and assets IN CASE something happens. What if nothing ever happens? Do you get a refund? I know it’s the smart thing to do, but it’s also a little fear-based, don’t you think? And the part about not getting a refund feels like a giant scam to me.
I read an article recently in a healthcare professional forum. It talked about a younger woman who was denied radiation therapy for a rare type of cancer. The decision came down to 3 men at Aetna who all held the title of Medical Director. The woman died and her husband sued. He won the case ($25 million) because “the jury ruled that Aetna recklessly disregarded its duty to deal fairly and in good faith with [the patient.]” Aetna’s defense argued that the treatment was “experimental” and expensive. It’s important to note here that for her rare type of cancer, there is no set treatment protocol. In addition, all three medical directors admitted spending more time preparing for the lawsuit than they did on her treatment decision. Was the cost savings to Aetna worth someone’s life? What if this was you or your loved one? This case helped to unveil what goes on at insurance companies behind the scenes. Claims, decisions, appeals, and approvals cross the desk of a “medical director” who may or may not be familiar with your condition. Very often, these medical directors are physicians who have been out of clinical practice for many years.
The same process occurs with drug coverage. A committee decides which medications will/will not be covered by your plan. The decisions are made primarily on cost and secondarily on efficacy. Generics are always preferred and often, new drugs require an authorization process. Step-therapy is a common cost-savings strategy for these companies. This means that you have to try and fail 2-3 older medications, often generics, to “qualify” for a newer, more costly one. This causes major frustration for patients who are seeking relief and binds physicians and pharmacists to a strict code. I know many people who are suffering through this process right now. They know exactly which medications work, but don’t have access to them without astronomical copays.
The players in this story are government, medical insurance, and drug companies. Government and insurance are fighting for lower prices and cost savings. Insurance and drug companies are fighting to grow their profit margins. Meanwhile, our nation gets sicker and more overweight year after year, thanks to our food industry, and medical costs grow exponentially. This is what I like to call the “black hole of healthcare in America.” Disease and illness are big money. Do the drug companies really want you to get better? If you do, they won’t sell anything! Do the food companies really want to create foods that contain quality ingredients and whole foods fresh from the farm? No! That’s way too expensive to manufacture! Cheap ingredients easily made in mass quantities with long shelf lives have been their formula for success.
I can’t help but think that the SMART approach is for each of us to do everything in our power to get healthy. As more mergers and acquisitions occur, the “power” in this space is being handed to fewer giants who will eventually control everything. Right now, the CVS-Aetna, Cigna-Express Scripts, and Walgreens-Humana mergers are all occurring. These companies are already giants joining forces with each other to become mega-giants. Did I mention that Amazon has also entered the health space and huge hospital systems are joining forces across state lines? Our healthcare system is constantly being redefined and you, the patient, have no control over what you see and what you get. Drug shortages and tainted drugs are also a very common thing that often reach only pharmacists’ ears. Everyone else doesn’t find out until it’s sometimes too late. It’s important to understand this because God forbid you should need some treatment or newer, expensive medication someday and not be allowed access to it. All because of someone who sits behind a desk and stamps “denied” on your paper (your life) without even looking at it.
Our mission is not to upset or scare you. Our mission is to educate and empower you, the consumer, with information that’ll help you make better decisions for your health and life. You can take control of your outcome or you can leave it in the hands of someone you’ll never meet or know if they’re truly qualified.
Chain Drug Review, Dec. 24, 2018, “Cigna Completes Express Scripts Deal.”
Doximity, Nov. 28, 2018, “Will the CVS-Aetna Merger Give Aetna Freedom To Kill?”
CNN, Feb. 11, 2018, “CNN Exclusive: California launches investigation following stunning admission by Aetna medical director.”