Medical care in the US is absurdly expensive; no one wants to pay for costly new treatments.
Ten years ago, the delivery of drugs in the US changed dramatically. "Pharmacy benefits managers" became a major force in healthcare. These managers could represent hundreds of health plans and aggregate their buying clout to create bulk purchases of drugs at a steep discount. The drugs were then sold to payers at a higher price -- the difference represented a profit for the pharmacy benefits manager. Acting as an intermediary and without meaningful transparency, pharmacy benefits managers made millions of dollars.
What value did they provide to earn this money?
To limit costs, pharmacy benefits managers and payers partnered to "manage" the adoption of expensive drugs. If a new drug could provide important benefits for 5 million patients, payers would suffer less financial pain if use of the drug were limited to only 500,000 patients. How might that be done?
- First, they might tell the pharmaceutical company that the evidence supporting the new drug was not compelling. (It did not matter if this was true!). Take a drug that is better than a generic in reducing the risk of myocardial infarction but it did not reduce the risk of cardiovascular death. Suddenly and unreasonably, the drug was deemed substandard -- even though preventing myocardial infarctions was certainly a good thing. So pharmacy benefits managers demanded a price cut.
- Second, they might delve into the data and identify artificial subgroups that appeared to benefit the most. If a drug reduced the risk of a clinical event by 30%, they would find a subgroup that benefited by 35%. They would approve use of the drug only for this subgroup, and not for the subgroup that benefitted by 25%. This was not a scientific process; differences in the responses in subgroups were probably due to the play of chance. The real problem: those who appeared (by chance) to have benefitted a bit less were likely to be deprived of the drug altogether.
- Third, they required prescribers to run the gauntlet of preauthorization. No matter how thorough the initial request, the initial response was typically "no". Of course, the physician could resubmit the form; eventually, the answer could be "yes". But physicians were not inclined to spend hours to make repeated efforts to gain approval of a new drug for each patient.
Physicians could hire a full-time person to tackle the preauthorization issues. Oncologists routinely have such a person embedded in their practices, but most cardiologists do not. Why the difference? Medical oncologists receive significant sums of money (in professional fees) to deliver oncology drugs to patients. In contrast, cardiologists do not make any money when they prescribe cardiovascular drugs.