Complicating Medicare and Medicaid

OPINION:

The greatest lie in politics these days is the term “free health care.” If there’s no such thing as a free lunch, then free health care is the most no-such-thing that never existed.

Publicly funded health care is a complicated, expensive thing. Any time a cost is shared, complexities will arrive that inevitably require compromises, difficult decisions and, yes, sacrifices. Those don’t make for good bumper stickers or tweets, and don’t expect to hear the word “sacrifice” from any of the two-dozen presidential hopefuls on the Democratic side who will inevitably embrace Medicare for All.

Real socialized medicine requires a lot of things America doesn’t have: A tiny population, excesses of natural resources, someone else to pay your military bills, and so forth. That’s why it works reasonably well in Scandinavian countries, for instance. These realities are important to bear in mind when some people talk about social programs that other people have to pay for.

However, a recent plan by the Trump administration goes too far the other way.

Last year, the Centers for Medicare and Medicaid Services (CMS) announced that health plans under Medicare Advantage can impose so-called “step therapy” on patients who need medicine covered by Medicare Part B.

What that means is the patient has to get treatment in steps — starting with cheaper alternatives preferred by the insurance company rather than their doctor. This of course creates an incentive toward short-term profits for the company, rather than long-term care for the patient.

For patients to get coverage for their doctors’ original prescription, they have to first work their way through those alternatives — those steps — regardless of how effective they may be, leading some to use the phrase “fail first” rather than “step therapy.”

In a recent letter to congressional leaders, 240 patient and provider groups raised concerns about the move. Some are fairly obvious: It restricts patients’ access to medicine they need, reduces choice, overrides doctors’ orders and creates potentially more problems in the long run. But another pitfall is that step therapy may force patients to “try older, less expensive medications that may not only be ineffective but could also lead to pain and adverse side effects,” the letter read.

That is of course in no one’s best interest.

The American Medical Association (AMA) has raised concerns that this policy shift will result in “unnecessary red tape” and more denials in coverage. Denying coverage is a common part of insurance, forcing patients and doctors to appeal an insurance company’s decisions or go without. Again, to keep things grounded, everyone can’t have everything all the time, but 75 percent of all Medicare Advantage denials get overturned during the initial phase of an appeal process. Which is to say, most denials seem to be unnecessary.

However, the appeals process can be confusing and overwhelming for those who lack the information advantage that insurance companies have. To wit, Medicare Advantage patients only challenge 1 percent of coverage decisions.

This change has an insufficient appeals process itself and very little transparency, as CMS has established almost no requirements on insurers that choose to employ “fail first” policies.

The “step therapy” policy took effect on Jan. 1. UnitedHealthcare — the largest provider of Medicare Advantage — has already moved to impose fail-first policies on the patients it covers.

If CMS does indeed choose to proceed forward with this policy, it should at least suspend the rule for a year to study the policy shift’s impact, which surprised many health care professionals, to come up with guidelines that all stakeholders could agree on.

Affordable, timely health care can require difficult decisions. Sometimes you could get an MRI, but you probably just need an X-ray. Everybody wants the fastest, most advanced treatment for the least money. That’s just normal. But to keep a health care industry for than 300 million people functioning, we are all going to have to make compromises, difficult decisions and, yes, sacrifices.

Step therapy, however, shouldn’t be one of them.

• Jared Whitley worked in the U.S. Senate, the White House and the defense industry.