Thanks for the useful reminder of where the for-profit BCBS plans came from. At the time of and since these conversions to the for-profit form, I've wondered how long the bubble would last ... and when the cracks would start to show. I don't want to imply that the issues are limited to for-profit insurance/medical care as many not-for-profits employ the same techniques. But we need to start thinking about and discussing in realistic terms what comes next and what public policies are needed to navigate to better ways of organizing, delivering and financing care. I agree, with MKBroker's comment and would add that "single payer" and "medicare for all" are fairly empty slogans: half (or more) of all Medicare beneficiaries are covered by Medicare Advantage. And, please, keep in mind that the way medical care is organized, financed, and delivered is not something separate and apart from the rest of the US economy: it is a major part of that economy and reflects the strengths and weaknesses of that economy.
I look forward to the discussion of "step therapy" hinted at in this article. I hope there's some nuance rather than "step therapy is always bad." I generally agree with that sentiment that step therapy is overused and harmful, but, there are circumstances where it might make sense. For example, patients starting with $25k per month stelara vs. the biosimilar Ustekinumab for $7k doesn't make a ton of sense unless there's a specific reason to pay more such as, the person tried the biosimilar Ustekinumab and it didn't work or there's some other specific health reason why Stelara is needed. We're all paying for each other's healthcare via premiums and/or taxes so that $18k per month difference matters for all of us under the current healthcare system or any type of single payer/universal healthcare system as well.
Before someone replies with the overly general response that single payer/universal healthcare is needed, health insurance companies and the greater system is corrupt, inefficient, untenable in the current form etc. etc. for which there are dozens of the same comment to every article. I agree.
See my story about my son in my comment. In general, I agree with your philosophical position, but the problem is that insurers/payors lack an understanding of the nuances in complex, multi-morbidity cases. So, cases like my son's are handled by non-medical personnel for approval or an algorithmic routine that automatically filters through a programmatic workflow. Never mind that the order has been placed by one of the world's most pre-eminent hematologists, who has a pretty good idea about what makes a sensible course of treatment for an individual patient.
I'm with you 100%. Thank you for sharing. Cases like your son's sound like ones where step therapy and prior auth is a real barrier to care. That being said, I expect there's a means to have both protect against waste (like in my Stelara example) while allowing for specific exceptions like in your son's case. I wouldn't be surprised if the folks reviewing your son's claim weren't hematologists at all, much less as qualified as your son's doctor.
How about if providers reviewing step therapy had to have the same specialty? What about if the turnaround times were days instead of weeks? What about if there is a presumption of coverage rather than vice versa? I don't work on the provider or carrier side, so handling step therapy/prescription drug coverage issues is not in my day to day and I'm sure there are far more experienced folks out there to address this. There must be a ways to better address both the need to avoid waste by prescribing needlessly expensive drugs when there are functionally equivalent options available while allowing for exceptions for cases like your sons.
Thanks, and you're not wrong about what should be done. I also work on the provider side and have been for the past 40 years. However, what I do know about the technology direction and motivation of these organizations is that they are not interested or motivated to solve that issue until somebody forces them. Sadly, the patients and their advocates have no leverage, and the providers are too busy caring for patients to put any pushback pressure.
The drive to AI usage in this process, to eliminate the in-house clinicians (Who are already on tight quotas for their review cases), means that we will likely see even more negative pressure on this process. Sadly, I suspect the insurers are motivated to throttle the process negatively (from a clinical/patient experience) as their motivation is to avoid/delay paying out for that care. Step Therapy is just another example of arbitrage techniques designed to keep money in the bank for as long as possible, rather than paying out. The bean counters know (I used to sell to wholesale insurers!) that an extra day of those dollars in their liquid balances is more capital they can flex in overnight investment plays.
Yes, I worked with the old AIG back in the 1990s, and that's exactly what their model was. Keep the secured reserves as tight as possible to their regulated minimums and utilize the remaining balance to participate in ultra-short-term markets. There are a lot more sordid little secrets about how Insurance companies generally keep and make money, but that's a much broader discussion
Stuart, could you contact a researcher with Wendell's team about sharing your family's step therapy story for a future article? Could you reach out by text 215-588-1547? Let is know, thanks
My experience with step therapy involved failing with medications I took unsuccessfully years ago. I currently take an old drug that has little profit value that the PBM has tiered up so much so Medicare needs to pay a fortune for it. It's malfeasance in both cases.
Oh man Wendell, yet again, you hit the mark. I too look forward to the future post on the horrible predatory practices in Prior Auth mechanisms. Step Therapy is a real pain in the but. My son has had chronically low Hemoglobin for the past 12 months since he had major abdominal surgery and several subsequent bleeds, two involving being life-flighted.
GI wanted him on Ferritin infusions. BCBS response. Well, he has to try a month of iron tablets before we consider that!!. Needless to say, after two rounds of appeals and three weeks of back and forth, he's finally getting the ferritin test now.
Would it have been easier for him to try the iron tablets that would have caused constipation, further jeopardizing his digestive function, sure, but sometimes you have to fight.
The time and inconvenience for his academic medical center providers in arbitrating the appeals process, and the continued distress physiologically and psychologically on my son, are immeasurable. And his Hg continued to fall.
I know there are numerous stories out there, and I am glad the market is finally starting to understand and penalize for-profit institutions for this behavior. I only wish those in Congress were not tied to the dollars flowing from lobbyists' checkbooks, and they might be bolder about regulating this kind of predatory behavior.
Does Leonard Schaefer’s rise coincide with our private for-profit healthcare diverting up to $79 trillion from the working class to the wealthy 1% over the last 50 years.
The Medicare for All Acts House Bill 3069(Jayapal & Dingle) with over 100 co-sponsors and Senate Bill 1506. (Sanders) with 15 co-sponsors were introduced in Congress on April 29th. Call your representative at 202-858-1717 and Senators at 202-519-0494 to cosponsor these bills.
This event brought on a flood of others, repurposing health insurance companies away from taking care of people and into high gear competing for profit margins. In the 70s we could still issue policies for people on a guaranteed-issue basis. A family plan would cost maybe $300 per month. Now, here we are, with profit incentives driving our health care.
Ask an insurance agent. We know it's wrong and were there when it happened. Thank you for writing this piece - I believe it is the ultimate explanation for what has gone so wrong with America's health plans.
Thanks for the useful reminder of where the for-profit BCBS plans came from. At the time of and since these conversions to the for-profit form, I've wondered how long the bubble would last ... and when the cracks would start to show. I don't want to imply that the issues are limited to for-profit insurance/medical care as many not-for-profits employ the same techniques. But we need to start thinking about and discussing in realistic terms what comes next and what public policies are needed to navigate to better ways of organizing, delivering and financing care. I agree, with MKBroker's comment and would add that "single payer" and "medicare for all" are fairly empty slogans: half (or more) of all Medicare beneficiaries are covered by Medicare Advantage. And, please, keep in mind that the way medical care is organized, financed, and delivered is not something separate and apart from the rest of the US economy: it is a major part of that economy and reflects the strengths and weaknesses of that economy.
I look forward to the discussion of "step therapy" hinted at in this article. I hope there's some nuance rather than "step therapy is always bad." I generally agree with that sentiment that step therapy is overused and harmful, but, there are circumstances where it might make sense. For example, patients starting with $25k per month stelara vs. the biosimilar Ustekinumab for $7k doesn't make a ton of sense unless there's a specific reason to pay more such as, the person tried the biosimilar Ustekinumab and it didn't work or there's some other specific health reason why Stelara is needed. We're all paying for each other's healthcare via premiums and/or taxes so that $18k per month difference matters for all of us under the current healthcare system or any type of single payer/universal healthcare system as well.
Before someone replies with the overly general response that single payer/universal healthcare is needed, health insurance companies and the greater system is corrupt, inefficient, untenable in the current form etc. etc. for which there are dozens of the same comment to every article. I agree.
https://youtu.be/62kxPyNZF3Q?si=2-5_XZhJLZkLJqy-
See my story about my son in my comment. In general, I agree with your philosophical position, but the problem is that insurers/payors lack an understanding of the nuances in complex, multi-morbidity cases. So, cases like my son's are handled by non-medical personnel for approval or an algorithmic routine that automatically filters through a programmatic workflow. Never mind that the order has been placed by one of the world's most pre-eminent hematologists, who has a pretty good idea about what makes a sensible course of treatment for an individual patient.
I'm with you 100%. Thank you for sharing. Cases like your son's sound like ones where step therapy and prior auth is a real barrier to care. That being said, I expect there's a means to have both protect against waste (like in my Stelara example) while allowing for specific exceptions like in your son's case. I wouldn't be surprised if the folks reviewing your son's claim weren't hematologists at all, much less as qualified as your son's doctor.
How about if providers reviewing step therapy had to have the same specialty? What about if the turnaround times were days instead of weeks? What about if there is a presumption of coverage rather than vice versa? I don't work on the provider or carrier side, so handling step therapy/prescription drug coverage issues is not in my day to day and I'm sure there are far more experienced folks out there to address this. There must be a ways to better address both the need to avoid waste by prescribing needlessly expensive drugs when there are functionally equivalent options available while allowing for exceptions for cases like your sons.
Thanks, and you're not wrong about what should be done. I also work on the provider side and have been for the past 40 years. However, what I do know about the technology direction and motivation of these organizations is that they are not interested or motivated to solve that issue until somebody forces them. Sadly, the patients and their advocates have no leverage, and the providers are too busy caring for patients to put any pushback pressure.
The drive to AI usage in this process, to eliminate the in-house clinicians (Who are already on tight quotas for their review cases), means that we will likely see even more negative pressure on this process. Sadly, I suspect the insurers are motivated to throttle the process negatively (from a clinical/patient experience) as their motivation is to avoid/delay paying out for that care. Step Therapy is just another example of arbitrage techniques designed to keep money in the bank for as long as possible, rather than paying out. The bean counters know (I used to sell to wholesale insurers!) that an extra day of those dollars in their liquid balances is more capital they can flex in overnight investment plays.
Yes, I worked with the old AIG back in the 1990s, and that's exactly what their model was. Keep the secured reserves as tight as possible to their regulated minimums and utilize the remaining balance to participate in ultra-short-term markets. There are a lot more sordid little secrets about how Insurance companies generally keep and make money, but that's a much broader discussion
:-) Thanks for being understanding.
Insurance induced Pain and suffering can be controlled with 1700% rise in stock price.
Stuart, could you contact a researcher with Wendell's team about sharing your family's step therapy story for a future article? Could you reach out by text 215-588-1547? Let is know, thanks
I’d rather you messaged me on my professional LinkedIn page if you dont mind my paranoia. The link is in my Substack profile.
My experience with step therapy involved failing with medications I took unsuccessfully years ago. I currently take an old drug that has little profit value that the PBM has tiered up so much so Medicare needs to pay a fortune for it. It's malfeasance in both cases.
Oh man Wendell, yet again, you hit the mark. I too look forward to the future post on the horrible predatory practices in Prior Auth mechanisms. Step Therapy is a real pain in the but. My son has had chronically low Hemoglobin for the past 12 months since he had major abdominal surgery and several subsequent bleeds, two involving being life-flighted.
GI wanted him on Ferritin infusions. BCBS response. Well, he has to try a month of iron tablets before we consider that!!. Needless to say, after two rounds of appeals and three weeks of back and forth, he's finally getting the ferritin test now.
Would it have been easier for him to try the iron tablets that would have caused constipation, further jeopardizing his digestive function, sure, but sometimes you have to fight.
The time and inconvenience for his academic medical center providers in arbitrating the appeals process, and the continued distress physiologically and psychologically on my son, are immeasurable. And his Hg continued to fall.
I know there are numerous stories out there, and I am glad the market is finally starting to understand and penalize for-profit institutions for this behavior. I only wish those in Congress were not tied to the dollars flowing from lobbyists' checkbooks, and they might be bolder about regulating this kind of predatory behavior.
Does Leonard Schaefer’s rise coincide with our private for-profit healthcare diverting up to $79 trillion from the working class to the wealthy 1% over the last 50 years.
The Medicare for All Acts House Bill 3069(Jayapal & Dingle) with over 100 co-sponsors and Senate Bill 1506. (Sanders) with 15 co-sponsors were introduced in Congress on April 29th. Call your representative at 202-858-1717 and Senators at 202-519-0494 to cosponsor these bills.
This event brought on a flood of others, repurposing health insurance companies away from taking care of people and into high gear competing for profit margins. In the 70s we could still issue policies for people on a guaranteed-issue basis. A family plan would cost maybe $300 per month. Now, here we are, with profit incentives driving our health care.
Ask an insurance agent. We know it's wrong and were there when it happened. Thank you for writing this piece - I believe it is the ultimate explanation for what has gone so wrong with America's health plans.
CA Lic. 0488272