Diabetes Blogs

Will Insurance Companies Start Punishing Us for High A1Cs?

Big Pharma NeedleJust what is to stopping pharma from dictating health insurance benefits based on A1C levels that they set for you? (Photo: 123rf)

When I was in high school, we were given a book to read by George Orwell titled1984. The book takes place in a fictitious location called Oceania and is ruled by The party headed by “Big Brother”.  

Written in 1949, many phrases have stood the test of time and became acceptable terminology. Phrases such as Orwellian, 2+2=5, newspeak, and big brother is watching are all credited to the book that was written about a completely made up future world.  Nineteen eighty-four was written 38 years ago is still relevant. We still ask, “Is big brother watching?”

These days, with modern technology being what it is, I find myself asking if the book was as much a ‘real’ look into the future as it was fictitious?  I also ask if perhaps we need to pay attention to the warnings outlined in it because if Big Brother was feared to become a reality and watching us, there's good chance it will happen as never before and that should be a big red flag for those living with diabetes.

How Diabetes Costs Got So High: An Explanation

With the recent outcry of the cost of insulin and other costs associated with diabetes spiraling out of control (David Spero, BSN, RN, wrote recently in Diabetes Self Management health-care spending for people with diabetes under age 65 in 2013 averaged $14,999, compared with $4,305 for people who don't live with diabetes), I find myself not asking what the problem is, because we know what the problem is; I find myself asking why nothing is being done about it?  

Research shows us that much of why we pay so much for insulin is due to the Pharmacy Benefits Managers or PBMS, for short. According to the National Community Pharmacists Association (NCPA), PBMs are described thusly:

Pharmacy benefits managers (PBMs) are middlemen that were originally designed to reduce administrative costs for insurers, validate patient eligibility, administer plan benefits as well as negotiate costs between pharmacies and health plans. Over time, PBMs have taken advantage of their strategic position between the insurer and provider to assert control over most aspects of prescription drug transactions. 

Today, PBMs are complex business entities with multiple, extremely profitable, revenue streams. The three largest PBMs manage drug benefits for approximately 95% of Americans with prescription drug coverage and each of these companies has annual revenues exceeding $15 billion. In spite of these facts, PBMs are virtually unregulated at the state or federal level—even though they manage numerous prescription plans funded by taxpayer dollars.  

So the question in my mind is more than if we know who controls these costs, that are completely out-of-control for those who need insulin JUST TO STAY ALIVE, and no one is stopping the practice; where will it end?  Think about it, according to NCPA three companies are controlling the cost of 95% of our prescriptions and the cost of insulin is not what scares me the most.  What scares me most has not happened yet but with this lack of oversight, transparency, and/or concern, what scares me most is just a matter of time.

Compliance!

That’s right.  If NO ONE seems to have ANY WANT OR NEED to reel-in the absolute control of “…these three companies….”  what will stop them from saying that on XYZ date, all those with diabetes (all types) must report their A1Cs to their insurance company?

Go back and look at any HIPPA form you fill out—at any medical facility in the country—and, in clear language, you are signing off for that office to share your medical information, ALL OF YOUR MEDICAL INFORMATION, with your insurance company.  If you are like me, you think this has to do with billing information, why would we think it is for anything else……right? Maybe. Maybe not.

Because now armed with all of our medical information, what is stopping any of these companies— based on advice from the PBM—to advise the following:

Dear Thomas,

It has come to the attention of BIG PHARMA INSURANCE COMPANY, your wonderful  insurance company, that your child’s recent visit to your doctor’s office showed an A1C of 8.7%. It is the decision of BIG PHARMA INSURANCE COMPANY that unless you can lower your child’s A1C to less than 7.5% (NOTE: BIG PHARMA INSURANCE COMPANY is graciously giving you .5% over the norm) the premiums you pay for your pharmacy benefits will increase by 25%.

We are doing this for your own benefit so you can enjoy a healthier, happier life.

Sincerely,

Your BIG PHARMA INSURANCE COMPANY


P.S. We care about you! 

I hope reading this scares the hell out you as it did to me when writing it. There has got to be a better way and when you consider that according to Open Secrets,  in 2018, the top five pharmaceutical lobbyists alone spent in excess of 38 million dollars protecting their interests in government affairs, I do not see any changes in the near future, and probably will get worse.

There are various outreaches slowly coming around to change these parameters, but we all fell asleep at the wheel and allowed the cost of insulin to spiral out of control without any transparency whatsoever. Now, blatantly and without any checks and balances, the cost just continues to rise. If this goes continually unchecked and corrected, it is my absolute fear that not only will we not be rewarded for having good health, we will be punished. 

Big Brother will be doing so much more than just watching.

I am a DiabetesDad

No comments yet.
Discuss/Comment
MAIN MENU