Managed care: Advancing affordable individualized care

How many of us really know the costs or medical efficacy behind every prescription drug we take? It’s tough enough to pronounce the drug names correctly, let alone recall the laundry list of side effects.

I am reminded of a standup comedy routine by Jerry Seinfeld where he talks about how drug companies view their customers. Like the illustration, we are viewed as the classic picture of a human body, face turned sideways, extremities extended, no eyes and our mouths always wide open ready to ingest the medicine they’re prescribing.

Unfortunately, we often blindly and inherently trust the opinions of our doctor and the marketing suggestions of drug makers when it comes to medicine. Furthermore, our doctors and drug makers are too often unable to quantify the anticipated cost of the treatment they are suggesting compared to other equally effective treatment options. That can be a dangerous combination and a sure sign that individualized care is lacking, and out of touch with keeping healthcare affordable.

This is why health insurance providers are constantly working to deploy and improve utilization management best practices and value-based payment models. Health insurance providers initiate techniques that doctors and drug makers must follow such as prior authorizations, step therapy and other protocols for using equally effective generic medications first.  

• Do you think drug makers want you to try a similar or cheaper medicine that costs you less before taking their brand name drug? Unlikely.
• Do you think your well-intended doctor is fully aware of the costs you could otherwise avoid if they used other similar forms of treatments or drugs they’re prescribing you? Unlikely.

These daunting tasks should not fall on you alone! Your health insurance provider strives to force doctors and drug companies to develop individualized treatment plans by prioritizing the medical efficacy of their customer’s care at the right cost. In recent months, doctors and drug manufactures have targeted health insurance providers for these value-centric changes. They like to argue that these changes interfere with medical privileges. They have called for the elimination of prior authorizations, step therapies, and other such utilization management controls that have unfortunately become the only way to keep healthcare affordable. These best practices simply require their justifications for medical procedures and encourage the use of clinically appropriate, safe, and less expensive treatments and similar medicines first, which cost you less. They don’t like the checks and balances because these changes are forcing them to engage and understand their patients’ health care benefits more personally.

Hopefully, the days of a doctor telling you to call your insurer after your visit to find out the costs of their treatment or their prescription will be a thing of the past. Imagine a day when patients won’t have to navigate the costs of prescription medications or medical treatments alone. Until then, health plans will lead the way to keep healthcare affordable by pushing drug makers and doctors to better understand and individualize their care for you.