I read this excellent post The Irrational Rationing of Health Care on LinkedIn by David Katz, that documents a case of denial of a treatment option to a patient because the payer considers that ‘not established as standard therapy for that cancer’ – as documented in their business criteria. As you would have guessed that the treatment option is a reasonably expensive one. This is an excellent article and an exemplary case for what I elaborate in previous blogs http://bit.ly/ACOSteadyState and http://bit.ly/sustainablehealthcare .

Yes, the advances in available treatment options puts heavy burden on payers – and most of the time payers are ruthless and act against the purpose of their existence. This puts anguish and many times irreparable damage to patients and heavy burden on sympathetic physicians. We, and they (payers), have to accelerate the newer options that are available for them (as never before in the existence of that industry) to recover costs in other ways available to improving efficiency and margins. My guess is the motivation for such actions are a combination of: (i) payers are behind in effective adoption of options in other fronts for cost control with new advances – so they see newer treatment options only as a cost burden, (ii) those cost containment options take time to pay back, and treatment options are evolving faster and (iii) payers are greedy to reap the benefits by trying to maximize as much margin till an effective law or regulation is imposed on them to stop this business practice. Let us hope they do not make it a practice to be fair only when regulated strongly – which is not good for them. Often payers end up spending more money cumulatively by trying to deny something that seems to be expensive care option at the current point in time, or sadly let the patient die.

As a society, the onus is on us to both help the payers as well as regulate them, but keeping their capitalistic needs in perspective. The recent and rapid developments in healthcare market have left too many loopholes that payers as well as many care practices (physician offices, hospitals, etc.) exploit to squeeze out more from the system.

As I wrote in an earlier blog http://bit.ly/ACOSteadyState, “To avoid such a scenario, the system: patients, physicians (and other care providers), payers and regulators have to simultaneously achieve their goals of patient care and cost control while balancing everyone’s financial incentives – without burden on one of the players in the equation.” Who is going to take up this responsibility? Only a healthy dialog and thought leadership involving all players will reveal the answer for that – we need to get there rapidly to avoid heavy burden of course correction.

Finally, this also reminds me to reach out to an experienced and knowledgeable physician who said in a recent meeting, that ‘when treatment options are available, the single determining factor if the patient has access to it is if they have access to physicians‘. Will update when I get a chance to discuss, or even ask if he is willing to write a post on that.

So, how do we get care to ‘medically deserving’ (definition needed) patients to whom therapeutic options are available even if they are classified exploratory/experimental by payers – under current rules or loopholes – with the evolving healthcare market?  Share what you think using the comment option.

Picture based on a reflection captured from subway window in Zurich. It is modified and used to show four major facets in healthcare: Patients, Providers (of healthcare), Payers and Regulators.