Insurance

The meaning of insurance depends on context. Life Insurance was the first model. It was a way to distribute a relatively large sum of money on the occasion of a rare event. Health insurance distributes generally smaller amounts of money more frequently. The trigger for the distribution of health insurance funds  is more nuanced. Death is absolute; but  everyone alive  is dying. Services to prolong life are constantly being sold. A complex contract, insensitive to the most important situational aspects, determines which goods and services will be paid for. Were it not for the contract, health insurance could not survive. 

The rise of liability, motivated by the personal automobile, made some forms of insurance a legal mandate. A legal requirement for insurance protection from from liability spread to professional endeavors and  corporate endeavors. Insurance became a way to guarantee a payment that was so large it could bankrupt the  driver or provider of services. The addition of the legal mandate in these contexts, ultimately justified such requirements in medical care.

Insurance supported Medical Care has different meanings in different countries. In  countries that make State supported Medical Care a right of citizenship, insurance is more of an assurance. it is the structure of the guarantee for the services and the method for accounting. In the United States insurance companies are the  recipients of premiums and payors of benefits, and they keep the difference. 

I suspect that the insertion of an agency that controls sums of money beyond the reach of most people,  and agency that is billed in lieu of the individual receiving the service, ultimately makes the services more expensive. From a supply and demand point of view, the supply of money becomes essentially infinite.  The limitation on price becomes a public relations issue. I think that the involvement of insurance in medical care has made it much more expensive and continues to do so 

 The responsibility for containing  Healthcare costs  in the United States has been transferred primarily to insurance companies. It Is clearly  in the insurance company's interest to pay less for the goods and services it receives. Over the past couple of decades, that has made it necessary to review an increasing number of individual cases. Many  treatments can cost in excess of $500,000 per year. Limiting those payments can be significant.  On the other hand, treatments that are being limited by insurance companies maybe the optimal course for some patients. the contract, the written document, may not be sensitive to the situation and recognize all of the consequences of the decision. On the other hand, the prescribing physician may not have a deep awareness of the marginal benefit that is being bought. A review of the  potential benefits, potential harms, and costs may be beneficial to the patient’s outcome.  It would be nice if this were made easy!

As it stands now, health insurance is the assumed provider of funds for health care. Health insurance is presumed when care is sought and provided. Health insurance has the final say over what will be paid for, Although there are legal limitations. A rather high level of service is required and insurance companies must pay for these in accordance with stipulations in the contract. 

The relationship between insurance companies and the provision of healthcare services grows ever deeper. . Medical trainees are taught which regimens insurance companies will cover, independent of efficacy and side effects.  Treatments with a reputation for insurance approval are generally the recommended ones. To do otherwise involves letter writing, phone conferences, and delay with no guarantee of success. Thus, the insurance decision becomes the medical decision. 

While doctors can legally prescribe any FDA-approved drug, insurance companies  exploit  the specific language of a drug's approval to delay access to newer, usually more expensive, medicines. The FDA’s published approval often includes a statement that a drug is for use only after a patient has tried one, two, or three, or more ... prior therapies. This language is intended  for the package insert, to limit the drug's advertising; but insurance companies use  it to refuse payment. This practice, which evolves into physician- accepted limitation, sometimes forces  patients to take more toxic and less effective therapy first. Only after these treatments fail can they "qualify" for less toxic, more effective treatment. This system delays optimal care while allowing drug companies to continue extracting profits from older, still-patented medicines. The pre-RFK FDA had some deep, consequential flaws. (I have not seen any progress on this problem yet). 

The stepwise wording of FDA approved package inserts has some justification.  It generally reflects the nature of the population whose improvement with the new therapy justified its approval. New therapies are rarely the first thing a doctor tries. New things are tried on patients who have failed several prior lines of therapy. The observations of lesser toxicity and greater efficacy (when that occurs)  is taken as the less reliable observation. Such low toxicity and efficacy may ( or may not) have required the prior (failed) treatments. Is this truth in the service of profit?

A decade ago, a medical journal drug advertisement required the full package insert. The first few paragraphs contain the ( presumed) mechanism of action. That is now gone. The indications (which diseases and after how many failed therapies) ,doses and side effects are presented. Who needs more?  Revealing the presumed mechanism could lead to off label usage, based upon an incompletely supported supposition of analogy. The mechanism could lead to the anticipation of unlisted side effects. It is gone from the ad. Understanding is no longer part of the job. 

Is there a better way to handle these issues? I think that there are currently places that are already doing that.  The biggest difficulty is examining the fundamental assumptions ( the value of the free market, the way that economic motivation plays out for discovery and distribution, the question of health as a human right, etc.). Later?