I am not sure if what follows applies exclusively to CIGNA, but it might provide some insights about why health costs are escalating.
CIGNA will not pay for expensive anti-inflammatory drugs unless they are the only alternative. Now consider the story of two patients. Both go to see their family physician because of a painful muscular injury. Both patients had in the past a stomach ulcer caused by the inexpensive anti-inflammatory drug Naproxene.
Patient 1: When the doctor tells him he will prescribe Naproxene for the pain, the patient tells him about his previous ulcer. The doctor knows CIGNA’s procedures and how to deal with them. He prescribes Vioxx knowing that CIGNA will not allow the pharmacy to fill the prescription. After this rejection, he will need to write a letter to the company explaining that the patient had a stomach ulcer. Because the approval can take a week or more, in the meantime the doctor gives the patient free samples of Vioxx so he can start the treatment. Finally, CIGNA approves the prescription, and the patient can buy the medicine to complete the treatment. This is a little roundabout and complicated, but in the end the optimal outcome is obtained: the patient’s injury is cured without suffering a serious side effect.
Patient 2: The doctor is having a very busy day and forgets to ask the patient if he had trouble in the past with regular anti-inflammatory drugs. He prescribes Ibuprofen, which is similar to Naproxene, but the patient unfortunately doesn’t know that. The patient starts taking the Ibuprofen and his stomach almost immediately starts to bleed. Recognizing the symptoms of an ulcer, the patient again calls the doctor. The doctor asks him to stop the Ibuprofen and take other medicine to cure the ulcer. The patient now continues with his painful muscular injury but on top of that has an ulcer. After a month or so, still suffering from the injury, the patient goes to see the doctor again, and this time he prescribes a safer anti-inflammatory drug. This time the drug cures the patient’s injury, but the ulcer starts to bleed again. So the patient has to see the doctor again, and again the doctor prescribes a drug to treat the ulcer. The doctor also refers the patient to a gastroenterologist. The patient sees the gastroenterologist, who tells him he will need to do a battery of tests to see where the bleeding is coming from. With the tests in hand the gastroenterologist finds that the patient has a serious intestinal inflammation. He informs the patient that although the problem could have been there for some time, the anti-inflationary drugs must have worsened the inflammation. He prescribes the patient the maximum dose of a specific medication for that problem and tells him that this being a chronic illness, he would need to be on this medication for the rest of his life. The patient initially accepts his fate, but after a while decides he needs to know a second opinion from an expert. In sum, this is the worst possible outcome: the patient is not promptly cured from his injury and suffers serious side effects, including weight loss, anemia, and (possibly) a very serious intestinal inflammation that might require frequent medical follow-ups and intensive use of medication. Besides the patient’s worsening health, the costs for CIGNA are orders of magnitude higher than a simple prescription of Vioxx or a similar drug.
What do we learn from this? The doctor of Patient 2 certainly made a serious mistake. But one should wonder whether this was not an accident waiting to happen. Because doctors are pressured by companies like CIGNA to always go for the cheaper drugs, and because navigating the system of administrative controls in the best interest of the patient, like the doctor of Patient 1 did, is complicated, aren’t doctors predisposed to make this type of error? If this is the case, aren’t the complicated regulations of HMOs like CIGNA presumably aimed at keeping health costs under control, in fact contributing to making these costs skyrocket? More importantly, aren’t these companies supposed to maintain rather than ruin our health?
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