By Mat Kladney, M.D.
Reno (Nev.) Gazette Journal, March 20, 2018
This year’s flu season has been particularly nasty, with more than 4,000 people dying from the virus every week. What’s even worse is that this year’s vaccine was not particularly effective, only preventing flu in about 30 percent those who got a shot. During the past two months, many patients have come to my clinic seeking care for influenza. Fortunately, we can prescribe Oseltamivir (Tamiflu), a treatment for patients who seek care within the first two days of illness. This treatment shortens the length and severity of illness associated with influenza, and also decreases the spread of the virus from person to person, which is absolutely key in preventing further infections.
Because this medication is only effective if given during the first two days of illness, it is crucial that it is given as soon as a diagnosis of influenza is made. This month I diagnosed a patient with influenza and prescribed her Oseltamivir (along with plenty of fluids, handwashing and rest). She went to the pharmacy and was told that her insurance would not pay for her medication without a prior authorization, a fancy term for “your doctor needs to speak with the insurance company in order to have this treatment covered.” By the time I was able to obtain the prior authorization for her treatment, the 48-hour window had passed, rendering the treatment useless.
Prior authorizations are used by insurance companies to reduce costs by guiding physicians towards cheaper options or medications. Such treatments are favored due to business agreements between pharmaceutical and insurance companies. By denying access to Oseltamivir, the insurance company placed countless people at risk of contracting the flu and my patient at risk of complications like pneumonia, respiratory failure and death. Additionally, the insurance company saved about $120, the cost of one course of Oseltamivir.
The prior authorization process is another symptom of our broken health care system, where private insurers decide that profits are more valuable than health. The perverse system gives insurance companies no incentive to promote community health. We must not forget that an insurance company is just that — a company, motivated by shareholder profits and driven by greed rather than health. My patient and her friends, neighbors and family were placed at risk for $120!
What is the solution to this broken system where greed trumps patient health? Adopting a single-payer health care system will take profits out of the equation and return the focus to patient and community health. Countries around the world have proven that such a system is possible by providing high-quality care at a significantly lower cost than what we pay in the U.S. We keep telling ourselves that competition and market forces will drive costs down, but decades of experience have shown this to be untrue for health care. Our health care costs continue to rise because a market-based system prioritizes profits — the opposite of what I want my health care provider thinking about when caring for me.
Bernie Sanders has been advocating for a Medicare-for-all system for years and recently introduced S.1804, The Medicare for All Act of 2017. Like H.R. 676 in the House, it would improve Medicare by covering all medically necessary care, including dental, vision and long-term care, and expand the program to cover everyone in the U.S., regardless of age, income or employment. These bills would develop a single-payer system in the United States and eliminate the waste, complexity and greed of private insurance. Our current health care system is bankrupting our country and costs will continue to rise as long as we have prioritized profit over health.
Dr. Mat Kladney is the chief resident for the Montefiore Medical Center/Albert Einstein School of Medicine primary care and social internal medicine residency program.