It is time for stewardship of our health insurance system

The bloated nature of health insurance in the United States has been a much-discussed topic in recent years. Particularly with the advent of the Affordable Health Care Act as well in response to physicians’ frustrations and increasing burnout from dealing with the constraints imposed on them by insurance companies, and at times being forced to provide suboptimal care for their patients in response to these constraints.

As an example, I had a patient recently who had an infection, neurocysticercosis, in her brain. This is a tapeworm that is found in undercooked pork and can in some patients travel to the brain and cause disease. This is not a common infection in the United States, but it is relatively more common overseas. This patient was becoming newly symptomatic from this infection and required treatment.

The primary and preferred therapy for this disease is albendazole, a common anti-parasitic drug that has been in use since 1982. We anticipated about one month of therapy until we received a call from the pharmacy indicating that the therapy was going to cost roughly $120 per day, which would come to approximately $3,600 for our anticipated treatment course. This medication cost only about $6 per day less than 10 years ago, and it currently costs less than $1 per day in developing countries where it is frequently given to all school-age children every few months as part of deworming campaigns. Our patient’s insurance, however, would not cover this medication. In fact, she was covered by Medi-Cal, the California version of Medicaid provided to patients meeting criteria for lower incomes, which is precisely the demographic most at risk for acquiring these parasitic infections, and yet they are the ones being denied coverage.

The dramatic price increase in this medicine in the United States was related to its acquisition by a private company that now has a monopoly on the medication and thus does not have any competitive incentive to maintain a reasonable price. This is exacerbated by the fact that we have no other cheaper alternative medications available for the same indications.

If we had a national health care system, however, the health care system also would have a monopoly, and these drug companies would then be pressured by the national health care system to offer their medications at reasonable prices, as there are likely few people who would be able or willing to pay for them out of pocket.

I use albendazole as just one egregious example of an aspect of the health care system that is significantly over-priced, and there are many other examples from many different facets of health-care. We must work to address these. There has been a recent trend in health care practice towards stewardship. I work in infectious disease and antimicrobial stewardship, related to judicious prescribing of antibiotics, was mandated by the Joint Commission for all hospitals in 2017. It has been mandated in California since 2014. There has likewise been a more recent emphasis on diagnostic stewardship.

Diagnostic stewardship relates to the ordering of diagnostic labs and imaging on patients and recommends against ordering unnecessary tests or tests that will not affect your management of the patient. It is time for our insurance companies to become stewards. Rather than denying most claims needlessly and inefficiently upfront, as discussed in Dr. Hoffer’s blog, it is time for them to return to the practice of providing affordable coverage to those who need it. The most successful model for this to work is a national model. As a united front, a national health insurance system has the opportunity not only to reduce overhead costs but to be a judicious steward of health care.

Medicare has already demonstrated success in this matter. By regulating reimbursement for certain drugs and procedures, it limits unnecessary tests and drugs and also helps to control prices. In Europe, there have been many complaints about long wait times for non-urgent surgeries, but as Dr. Young discusses in his recent blog post, this may not be a bad thing. In fact, it can be viewed as another form of stewardship as many of the surgeries with long wait-lists are in fact surgeries that have not proved beneficial in clinical trials. This, then, is another example of cost-saving measures and arguably improved patient care provided by a national health care model.

I recognize that America has many hurdles to cross to move towards a national health care system, but I think we need to continue to strive for it. We should not have to send our insured patients out on the street without medication for an infection in their brain because one company decided to set prices unfairly. And we should not have to waste millions of dollars on needless overhead required by having multiple different insurance companies with arcane rules and regulations, many of which work to restrict coverage to the actually sick. It is time for us as physicians to be thoughtful in our ordering of tests and treatments and procedures, but to work with insurance companies for the benefit of our patients, not against them.

Jenna Holmen is a pediatric infectious disease fellow.

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