Medical Costs and Responsible Stewardship

I specialize in the treatment of psoriasis. Our National Psoriasis Foundation has been an invaluable partner to me, helping me educate my patients about their treatment options, working to encourage companies to develop new psoriasis treatments, and funding research to help find a cure for the disease. One of the Foundation’s most important activities has been to help assure patients have access to needed treatments.

Among the current hurdles patients face, are health insurance coverage policies limiting the treatment options that patients and their dermatologists can choose. The Foundation contacted me about joining them in an effort to convince our state legislature to pass a law blocking unreasonable health insurer step edit policies. Medical decisions should be between patients and their doctors. There’s no place for insurers or governmental regulators to be interfering with these decisions. Or is there?

We live in a world of limited resources. Normally, the price people pay for things limits their choices. In turn, prices are limited because people choose not to buy items they find too expensive. But when it comes to medical care, patients don’t directly face those costs; the insurer is paying. The patient may not be paying anything if there’s a “zero copay card” being used. So if the patient/consumer isn’t paying, there’s no limit to what the buyer can charge, no limit to the resources patients may consume, and no limit on the rising price of medication.

Either we pay continually increasing prices with no limit, or someone has to take responsibility for saying no to a high cost product. If the patient isn’t taking responsibility for cost-effective decisions, who is left? Should it be the doctors? While some might make a strong case for doctors to choose, that would put us at odds with our patients, having to deny them the best available care. I doubt that’s a relationship with patients that we would enjoy.

We could let the government decide what treatments patients get. Other countries do that. Or, we can live with health insurers contracting with drug companies for preferred products and making policies, including step edits, that set limits on the options available to patients and doctors. That’s not ideal either.

The ideal approach would be for no limits on medical resources so that every patient could have access to the best care humanly possible. We don’t live in that world. Somebody—patients, doctors, insurers, or government regulators—is going to have to be responsible for making cost-effective decisions about medical resource use. Pick your poison. But don’t be too upset if society chooses a different regulator than the one you would choose. It may not be an ideal world, but our cups are far more than half full.


feldmanSteven R. Feldman, MD, PhD
Chief Medical Editor

Dr Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.