Summary: Two recent articles characterize systemic trends and illustrate one patient’s struggles with corporate goals, values, and tactics permeating health insurance.
Value-Based Payment Is the New For-Profit Health Care Industry
September 8, 2022
By Kip Sullivan, Kay Tillow & Ana Malinow
Like the insurance industry, the VBP industry hovers over doctors and patients and seeks to influence (and in some cases, dictate) doctor-patient decision-making, and in the process diverts resources away from medical care. Unlike the insurance industry, the VBP industry is almost invisible to the public. It consists of a heterogeneous mix of corporations that own, contract with, manage, consult with, or sell services to providers (doctors and hospitals). Some, such as “accountable care organizations,” mimic insurance companies. Others are consultants, such as Privia, venture capitalists like General Catalyst, or firms selling management services, such as agilon health. Large pieces of this new industry are being bought out by companies like Walgreens and Amazon. …
The phrase “value-based payment” emerged in the 2000s as the label for all methods of payment that shift insurance risk from insurance companies and public programs like Medicare onto health care providers. Risk is shifted by paying providers a set fee per patient per year (usually called “capitation”) rather than a fee for each service providers render (known as “fee-for-service”), or by tying provider payment to the profits and losses of organizations they contract with. VBP advocates claim, without evidence, that fee-for-service (FFS) induces doctors to order services patients don’t need and that shifting risk to providers will induce them to improve both components of value — cost and quality. …
The speakers at the [National Primary Care] “summit,” who included virtually every prominent advocate of VBP from the public and private sectors, studiously avoided discussion of VBP’s underwhelming effect on the cost and quality of health care, and rarely mentioned its worst side effects. A few speakers expressed frustration at how long VBP was taking to prove it can work, but even these speakers refused to discuss the research. Rather than acknowledge failure and use their time together to analyze the reasons for failure, the 150 speakers concentrated instead on repeating VBP folklore (fee-for-service is the problem and VBP schemes are the answer) and reporting cherry-picked anecdotes.
Tackling cancer while battling the insurance system
The Washington Post
September 9, 2022
By Annabelle Gurwitch
Even plans that are supposed to save patients money can end up costing them dearly
“You’ll receive a bill, but don’t pay it,” my caller [from SavOnSP Specialty Pharmacy] said. “Working with us ensures that you have a zero co-pay.”
[A[ few weeks later my monthly shipment of medication arrived along with an invoice from Express Scripts for $4,445. It noted that I might not owe this amount; nevertheless, it had a detachable payment slip, and a return envelope was provided. Remembering the caller’s assurances, I tossed the bill into my ever-expanding, supersize file I’ve labeled “insurance gobbledygook.” But when I visited an ATM the next day, my balance was significantly lower than I expected. $4,445 had been deducted by Express Scripts….
I’d been entangled in an increasingly exploitative scheme. In what’s become a standard industry practice, pharmacy benefit managers (PBMs) contract with secretive third-party adjusters commonly called co-pay accumulators and maximizer programs to process “specialty medication” prescriptions, including biomarker-targeted therapies for lung cancer and other chronic and deadly diseases. Once a plan engages a co-pay accumulator or maximizer, these entities reclassify these medications (some of the priciest on the market) as “nonessential.” This allows plans to exploit a loophole in the Affordable Care Act: Coverage can be denied for therapies that a plan labels “nonessential,” and a plan can reset the member’s pharmaceutical benefit deductible and out-of-pocket maximum to any amount of their choosing.
Comment by: Jim Kahn
Sadly, US healthcare is increasingly distorted by a rising corporate presence, most of all for insurance but also for care. Corporations create a mythology of benefit for patients and apply aggressive business models and tactics to extract maximum profits, to the detriment of the rest of us.
The first article describes the feverish expansion of value-based payment, an array of funding mechanisms focused on capitation (named as such and de facto), with only one clear and consistent benefit: profits for corporate intermediaries. We’ve written often in HJM about the most egregious examples – Medicare Advantage, DCEs, and ACO reach (just search your emails or the HJM website). Traditional standards of evidence in medicine are routinely ignored. Instead, if a strategy is profitable we hear mindless and mind-numbing assurances that it’s beneficial. Yet often there is evidence of harm. And often there is no evidence at all, due in part to withholding of proper evaluation data by corporate interests resisting scrutiny.
The second article brings home how this ethic affects the individual, with a startling example of a women with cancer caught in a thoroughly confusing web of drug insurance entities. These layered intermediaries are proliferating out of control (pharmacy benefit managers, adjusters, accumulators, maximizers). Each complexity and inadequacy of drug insurance represents another business opportunity, a 3rd and 4th layer “remedy”. It’s a daunting challenge for anyone to understand the myriad drug insurance entities and the sequence of events described in the article. Perhaps the slimiest aspect is reclassifying a drug for cancer treatment as “nonessential” in order to burden the patient with costs far in excess of the deductible.
When will we transform our health insurance to elevate people over profits? And society over shareholders?