By skyforbes 
Restricting your healthcare.
I am an internist working for a Medicaid health plan. In Oregon the Medicaid health plans are called Coordinated Care Organizations or CCOs. I’m relatively new to health plans and the idea of healthcare rationing was repulsive to me before I had this job when I was still practicing medicine. I couldn’t imagine not being able to treat patients with medications they needed. Rationing care was a bad word. I could sit on my high horse and act like an American expecting to get everything I wanted if I had the money to pay for it.
Now, with my three year’s experience working for a CCO I recognize how naive that was, to think we don’t ration care every day. And for good reason. We ration it every day for every person because we need to grow up and take care of our money. Be stewards to our financial resources. Find the waste and eliminate it, improve care while reducing costs. And in the end decide what will get paid for and what won’t.
Most health plans have a formulary. This allows health plans to restrict use of drugs to effective and lower cost options. Most time we have other options that are lower cost. Sometimes we don’t and that is when the restrictions on healthcare get real.
The most stark example is that of Hepatitis C treatment drugs. The average course of treatment costs ~$80,000. If the CCO I work for was to take its entire budget for all of its pharmacy ( all of the medications for heart disease, diabetes, asthma, cancer…everything) it would only be able to treat 25% of the Hepatitis C patients.
Even with the best price negotiations we could get the cost down to ~$40,000 per treatment course. We would still only be able to treat 50% of the patients with Hepatitis C…and nothing else.
Here’s what I am learning. The pharmacy companies will say they need the money for research but if we take a close look at the research costs they total in the millions while profits are in the billions…for those pharma companies that still do research.
Most recently I have learned of the pharma companies that don’t do any research. They acquire research companies and drug manufacturing companies fire 70+% of the staff set huge prices on the medications and report higher than expected earnings to their shareholders. I have a new level of disgust for pharma.
In the 90’s my disgust was for the heavy marketing to doctors and the direct ad campaigns. Now it is for the price gouging to beat all price gouging. The perversity of the CEO of a pharma company who used to be a hedge fund manager.
We are restricting your care right now and in significant ways because even though you do not have Hepatitis C* and even though you likely do not have Medicaid** you do likely pay for both. Where would you like your money to go? Legislative restrictions are needed and it will be an uphill battle to fight the pharma lobbiest. Their funding is second only to the NRA.
*dont be too sure you don’t have Hep C over 40% of Hep C is undiagnosed.
**>30 of the region I serve is on Medicaid so this may be you as well.