While hardworking Americans fight for health care, the health care insurance industry is secretly working to limit treatment options for patients through a pseudo-independent committee that threatens to stifle development of new breakthrough drugs.
A shadowy group founded and largely financed by insurance companies operates effectively as a front for the insurance industry to manipulate market prices and limit medical access for patients.
One particular challenge patients and their doctors face continues to be the black box of coverage decision-making. Without transparency on coverage decisions and appeals processes, patients and doctors are left with incomplete information.
Obamacare created a windfall for insurance companies, which now use an affiliated group in the guise of an autonomous organization to keep the information on their side.
The organization, the Institute for Clinical and Economic Review (ICER), provides insurance companies with a patina of supposedly “scientific” support to deny coverage for breakthrough drugs.
When a new drug comes to market, ICER simultaneously releases an “economic impact” report aggressively attacking the new drug’s efficacy and claiming that its market price is unduly high.
Perversely, the denial of coverage of new medications could increase health care costs, as patients are forced to accept short-term treatments rather than long-term cures. For example, curing hepatitis C lowers healthcare costs for all patients, including those with end-stage liver disease, according to a 2016 study.
Specialty drugs can cost-effectively increase both the quality and duration of life as compared to traditional drugs.
Denial of coverage or unreasonable barriers to access through preauthorization requirements and “fail first” protocols (when drugs must fail to help the patient before the patient receives coverage for a different option) can cause people to delay coverage which can lead to less desirable outcomes and increase costs over the long term.
Appropriate medical treatment requires a recognition that individual cases are uniquely different. Genetic research shows that some patients cannot respond to a one-size-fits-all medicine regime, and medical science underscores the advantages of personalized medical choices.
ICER touts itself as an independent drug-price watchdog but their stated goal is to set prices for health care based on its own view of drug efficacy and — in their own words — “not in accordance with what the market will bear.”
Most of ICER’s reports have found that the list price of new drugs is too high, oblivious to the reality that pharmaceutical companies can discover new drugs and bring them to market only if they can successfully recoup the enormous costs of drug development.
ICER’s express purpose, in so many words, is pharmaceutical market manipulation.
ICER receives much of its funding from major insurance companies and thereby has financial incentive to promote exclusion of new drugs from plan coverage.
ICER’s charter reserves three board seats for insurance company representatives while innovative drug researchers are shut out from board participation. The group’s president also previously worked for the insurance industry’s lobbying organization, America’s Health Insurance Plans.
Before that, he worked for the United Kingdom’s health care rationing board, the National Institute for Health and Care Excellence. The rationing board, known by the Orwellian acronym NICE, is a health care oligarchy that decides which drugs the UK government will cover.
Consumers should resist efforts to deny breakthrough medicines by their insurance companies. They can hold insurance companies accountable by demanding more transparency in decision-making and the appeals process.
As lawmakers prepare to overhaul the healthcare system as they look to ‘repeal and replace’ Obamacare in the Congress, they should focus on advocating patient choice and cracking down on the price-setting power of medical bureaucrats. Rather, they should allow market forces to work.
Consumers should object to ICER’s self-dealing market manipulation and combat the effort by insurance companies to distort market-based healthcare solutions.
First published in THE HILL in December 2016