HJNO Jan/Feb 2024

HEALTHCARE JOURNAL OF NEW ORLEANS I  JAN / FEB 2024 19 had an offer on the table, and it was now time to give my answer. I was driving home after a long day of seeing patients when the physi- cian called me for my answer, which was going to be no. Sensing the hesitation in my voice, he told me to stop talking for a moment. He said, “Kenny, I can sense your reluctance and so before you give me an answer, I want you to take a few days and think about something. I know you well enough to know that if you told me no it would be because you do not want to abandon your thousands of patients. So, just take a few days and think about the impact you can make on those thousands of patients in the system as it currently exists versus the millions of members of [our company] in a system that we can help shape and create.” I called him back two days later and accepted the offer. The people I worked with at that company were genuinely dedicated to their mission. I worked with some truly wonderful people, including several other physicians and plenty of nurses, all of whom took their responsibili- ties to their members very seriously. So, con- trary to the opinion of it being the “dark” side, these people considered it their duty to safeguard the health of their members and to do so in fiscally responsible ways that upheld their fiduciary obligation to them. However, coverage decisions by commercial payers are enormously complex. Insurers typically employ several physicians who act as medical directors to help guide these coverage decisions based on the latest scientific evidence. And there is a delicate balance to uphold between paying for services that are medically inappropriate versus lifesaving and medically necessary. Take cardiac stents for example. A recent study published in October 2023 by the Lown Institute found that, “U.S. hospitals gave a medically unnecessary coronary stent every seven minutes between 2019 and 2021. Recent study data suggest that the procedures offer no outcomes benefit com- pared to medication therapy for those with sta- ble or chronic coronary disease and open the door to adverse outcomes as well as elevated spending.” 1 However, when health insurers try to crack down on the number of these medi- cally inappropriate and potentially harmful procedures, they run the risk of being vilified for denying care. Now, there are certainly re- ported cases of individuals being denied medi- cally appropriate, lifesaving care by insurance liver cancer. These problems lead to repeated hospitalizations, frequent admissions to the intensive care unit (ICU), and inexorable pro- gression of the disease where the only “cure” was liver transplantation. All in all, the conse- quences of liver failure are not only horrible in nature but also outrageously expensive. Sev- eral hundred thousand dollars can be spent by a health plan covering the costs of these repeated hospitalizations, and if the patient becomes eligible for a liver transplant, then those costs can easily exceed $1 million. So, if a treatment becomes available that can cure the problem before any of these complications arise, thus preventing repeated hospitaliza- tions and/or liver transplantation, then $84,000 to $168,000 would seem like a bargain, right? “ Light” Versus “Dark” Side: Not as Simple as in the Star Wars Saga The movie Star Wars was released in an era where the motion picture industry tended to tell many of its tales in terms of good versus evil. The verbiage used to depict this tension was described as a “force,” which could be used for good but could also be perverted to entice someone over to the “dark” side. In pre- vious articles, I’ve described how leaving the full-time private practice of medicine was one of the hardest decisions of my life. I love caring for patients, and it remains the highest honor of my life to do so; but in the typical volume- driven model of primary care there just never seemed to be enough hours in the day to do it as well as I wanted. From the perspective of my colleagues, my leaving practice was bad enough, but to go work for a health insurer — the so called “dark” side of healthcare — seemed like outright heresy. I have to confess that if someone were to have told me as a med- ical student, resident, or early on in my profes- sional career as a practicing internist that one day I would go work for a health plan, I would have scoffed at the notion and told them that they didn’t know me at all. And yet that is ex- actly what I did. Truth be told, my initial answer to the offer of employment was no. I remember the day well. The physician who recruited me to come work with him had been trying to court me for over a year, both of us convinced that our healthcare system was in drastic need of change. I went through the interview process, In 2014, a new drug hit the healthcare mar- ketplace that rocked the world of both patients and health insurers alike. The drug sofosbuvir, sold under the brand name Solvaldi, was devel- oped by the pharmaceutical company, Gilead. The novel drug captured the attention of the world for multiple reasons. First and foremost, it represented something that is still all too un- common in healthcare—a cure. In this case, the drug could cure infection caused by the hepati- tis C virus (HCV). Chronic hepatitis C viral infec- tion was one of the top two causes of cirrhosis with liver failure, with the other being excessive consumption of alcohol. Sofosbuvir was a novel antiviral agent that effectively blocked ongo- ing viral replication, thus eradicating the virus, and therefore curing patients with hepatitis C. But the fact that we could now cure hepa- titis C was not the only headline generated by this new agent. The price tag for the drug likewise garnered its share of headlines. The drug was priced at $1000 per tablet. A treat- ment course consisted of one tablet daily with some people requiring a 12-week course and others requiring a 24-week course, in other words $84,000 for a 12-week course and $168,000 for a 24-week course. Insurers did not immediately rush to cover the cost of this medication for all patients infected with hepatitis C, choosing instead to cover those patients who were in more advanced stages of disease. Gilead, the drug manufacturer, justi- fied its pricing saying that it cost nearly $1 bil- lion to bring the drug to market and therefore needed to recoup their research and develop- ment costs. Other factors certainly played a role in the determination of pricing, including the need for better hepatitis C treatments — especially a cure — lack of competition, and lack of generic alternatives. Insurers, mean- while, started performing their own pharma- coeconomic analysis of coverage for the drug. The costs of treating liver failure are enor- mous. HCV infection causes liver inflammation that results in scarring or fibrosis in the liver of a significant percentage of the patients infected with this virus. Over time, the liver becomes in- creasingly scarred to the point where its func- tion is impaired, and a litany of problems en- sue. These problems include bleeding to the point of massive hemorrhage, severe swelling and volume overload, infections, encepha- lopathy, kidney failure, and increased risk of