Is Health or Greed Driving Health Systems?

Workers at the largest health system in the U.S., HCA, this week accused the system of putting profits ahead of patient care and health. We regularly hear from obesity care providers about insurers using lame excuses to deny coverage for obesity meds or surgery for lame reasons. This happens even when the health plan covers meds and surgery for obesity. The apparent hope is that patients will simply give up and the insurance won’t have to pay. So it seems reasonable to ask, is health or greed driving health systems?

Money vs Quality of Care

More than 7,000 nurses in New York City went on strike this week, demanding that their hospitals fix staffing problems with staffing levels. Those staffing levels are so low that they put patients and nurses at risk, say the unions that represent the nurses. But, of course, keeping staffing levels low does help with the financial performance of these hospitals.

Last year, says the Bureau of Labor Statistics, six unions representing 32,000 nurses in total called strikes at hospitals around the country. In fact those strikes accounted for one in four of all the major strikes that year. Nurses are objecting to low staffing levels that they say will lead to safety issues for patients. At HCA hospitals, the union that represents patient care employees says that low staffing levels contribute to patient care failures. But HCA profits doubled in 2021 while it fell well short on its own measures of patient care quality.

Does PBM Stand for Profits Being Maximized?

Actually, the PBM acronym stands for pharmacy benefit manager and the whole point is supposed to be negotiating lower prices on prescription drugs so that patients can have better access to them. But it doesn’t seem to work that way consistently. For example, the introduction of biosimilar (i.e. generic) insulin shows that PBMs seem to prefer higher priced drugs because they can pocket more profits from a steeper discount on the higher price. Viatris (Mylan) introduced two versions of their biosimilar to Lantus insulin. One was branded as Semglee and carried a high price only slightly lower than the price of Lantus itself. The other was generic with a much lower list price. According to Adam Fein, “Viatris had to nearly triple the list price of Semglee before Express Scripts would add the product to its formulary.”

But it’s hard to get a reading on the precise impact of PBMs on drug costs because they are not transparent about their business practices. In fact, much of what they do is cloaked by non-disclosure agreements.

Another abusive practice of PBMs (and health insurance plans) is their use of prior authorizations. They serve to discourage patients from seeking care for conditions that might be costly to treat. For example, a patient is getting good results from semaglutide (Wegovy) with a 1.7 mg weekly dose, but could not tolerate the full 2.4 mg dose that most patients receive. Express Scripts tells their physician, an international expert on obesity care, nope, we won’t pay for the lower dose. “If the patient cannot tolerate the 2.4 mg dose . . . Wegovy should be discontinued.”

This simply makes no sense.

Change Clearly Needed

Such games as these are costly to patients, but they pad the revenues of businesses in healthcare. So greed has its way of driving too many decisions in health systems. Change is needed because health must be the first concern. Not simply maximizing net income and profits.

Too many health systems have lost sight of their real purpose.

Click here for perspective on the very real phenomenon of greed. For more on issues with PBMs, click here and here. For more on patient safety and hospital staffing issues, click here and here.

Christ Overturning the Money Changers’ Table, painting by Stanley Spencer / WikiArt

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January 15, 2023