Taste of Reality

We all have stories about what is messed up with the healthcare system and have our own thoughts on the best way to improve things.  We have fought the political battles around healthcare reform and whether healthcare itself is something we must earn or are entitled to.  We compare the costs and outcomes of our system with those in other countries around the world.  We take great pride in what we do in the healthcare world and wonder why others don’t appreciate the industry and all we do.  Let’s take a brief glimpse at the real world.

This is the time of year when many of us need to select the healthcare plan we want to enroll in for the next year.  Medicare patients must go through a similar exercise to choose the best plan for their drug coverage.  At times it is a convoluted system where seniors are advised to look through the different formularies and choose the one that best matches the drugs they currently take.  Seems simple right?  Let’s take a look at the adventures of one such senior as reported in the New York Times.  As you read the piece try to put yourself in the senior’s place and feel what he must be feeling.  Try to also imagine 50 million other Americans trying to maneuver their way through the same maze at the same time.

Several things struck me as I read the article.  First, the person is obviously a financially astute individual given his experience with Forbes and Money magazines.  He also has a high level of patience and perseverance in his search for the truth.  He wants to choose wisely and do his part to manage the financial aspects of his disease but has no credible counterpart to help him with his dilemma.  Can you just imagine the hours invested in this search and the concern he must have relative to the incredible potential costs he must bear if he makes the wrong decision?  What if this person was not financially savvy?  What if he lacked the patience and perseverance?  What if he had less money and the wrong decision could mean bankruptcy and losing his entire life savings?

It is tough for me to even write about this issue as it is so mind boggling and makes our industry and the overall healthcare system look so bad.  I don’t want to pass judgement on any one drug but what is the upper limit?  Is it a million dollars a year?  How much should patients with insurance be expected to pay?  Is it all they can afford or is it all they have?  Can a system survive where nobody really understands how it works and patients can’t even get a straight answer as to who will have to pay what?  The stakes are very high and too often we take pricing decisions too lightly and make things so complex nobody can figure it out.  Keep in mind the dilemma this man is facing would be exactly the same for somebody with less money trying to determine how to afford even less expensive therapies.

Where will this all lead?  I think it can only go one of two ways.  Either the industry needs to fix things fast or the system will inevitably end up as a single payer system where everyone is covered by the government for both drugs and medical care.  Yes, like we see in the rest of the developed world.  The problem will be that the government will also determine which drugs they will cover and how much they will pay.  If our industry thinks this is a problem in Europe and other places around the world where there are severe pricing negotiations, think how bad it will be when the US goes that way as well.  There will then be no place on earth willing to pay anywhere near what is currently being paid in the US.  We better get real and fix things quickly before we face a new reality that nobody in our industry wants to see.

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