Medicare drug coverage is often inappropriate – here is why

The medicine of your father’s rheumatoid arthritis was functioning well, fighting that bad illness. Then he discovered that Medicare would no longer pay the medicine.

The multiple sclerosis of your thesis was lighting and its neurologist recommended a new promising treatment. But she learned that she would have to try, and “fails”, in two other medicines before Medicare covered the new one.

Many people pay for Medicare coverage and are surprised to find out that they still face important restrictions on those medicines they can take. Let’s see if I can predict the situation.

Rapid background information

When Medicare was created in 1965, she did not pay for medicines other than the coverage of patients with medication taken during hospital stays. That’s because there weren’t all those many medicines in 1965, and those around them were not very expensive.

Today, there are two ways of medical recipients receiving drug coverage. They can buy a drug coverage plan (Medicare Part D) from a private insurer to supplement their traditional government coverage (Medicare Part A for hospital expenses and part B for outpatient costs). Or can they give up parts A, B, and D and register on a Plan of Part C (still confused?), Also known as Medicare Advantage, where a private insurance company covers hospitals, outpatient care and medicines .

Holding down the cost of covering

After purchasing the drug coverage, the private insurers decided on their work to refund the drug costs while, at the same time, trying to keep those costs. Don’t work hard, at least yet, for this second job. American health care spends the dwarfs of any other wealthy country, and the cost of Medicare alone, threatens the fiscal stability of the federal government. If insurers do not try to maintain the cost of American medical care, who do you want?

How, then, do the insurers keep the costs of medication?

First, they negotiate prices. More specifically, they work with large corporate entities called PBMS (Pharmacy Benefits Managers) who take the lead in these negotiations. If five companies make medicines for rheumatoid arthritis, PBMS can play companies from one another and volume for lower prices.

But not every pharmaceutical company reduces its prices or reduces it as much as other competitors. And not all products have good alternatives. Thus, insurance companies/PBMS stimulate patients to choose less expensive medicines. They do it some ways.

1. Preliminary authorization: Before they agree to pay for a medicine, they require doctors or patients to obtain permission. When I had severe muscle dystrone a few years ago, I needed thousands of dollars in the botox injections every three months. Prior to each injection, I was expecting the approval of the insurance company to make sure they would cover the medicine.
2. Opening therapy: Want Z medicine for your rheumatoid arthritis? If X and Y are shown to help patients, and are less expensive, your insurance company may require you to try those two medicines first.
3. EXCEPT: An insurer can simply decide that the Z drug is very expensive and that it will pay only X and Y.

Trends in “Cost Management”

The three approaches listed above are becoming increasingly common. In 2011, about 1/3 of the drugs were limited by plans of part D, through prior authorization, therapy opened or excluding according to a study in health issues. By 2020, that number had increased to 40%. Here is a picture showing that trend:

For brand -named medicines, these restrictions are even more common. In 2011, 40 to 50% of those medicines were limited. By 2020, that number increased to 60%:

Cost control measures: good and evil

Many people are worried about these restrictions. Patients whose insurance plans change their formulas, receiving coverage for the medicines they have used; Patients who change insurance plans and should go back to step therapy, or spend precious time proving that they have already “failed” in lower -price medication; Clinics spending precious time by completing the documentation to obtain authorization for their patients.

On the other hand, many drug prices are high spectacular, often two or three times higher in the US than in other rich countries.

There are no easy solutions to this growing problem. But here are some preliminary suggestions.

First, centers for Medicare & Medicaid Services (CMS) must expand its efforts to negotiate medication prices, a practice that began only recently.

Second, CMS should require payers to simplify prior authorization. And it should make it easier for insurers and PBM to share information if patients have already failed in medication when in another insurance plan, accelerate the taking of the other relevant relevant medicine for their condition.

Third, lawmakers should continue to find ways to reduce people’s exposure to drug costs. The act of reducing inflation was a good start, setting a $ 2,000 a year of drug costs outside the pocket. This is still a huge load for many older people. Congress should reduce that limit for lower people in wealth and income.

Medicare was created in 1965 to help the elderly Americans pay for their basic medical needs. Drug prices have increased significantly since then, and coverage has not maintained the pace. Time to fix our security network.