Health Care Reform Must Directly Address Problems Facing Patients

Democrats are right to tackle the issue of rising health care costs. Patients need help: insurance companies charge ever higher deductibles and Pharmacy Benefit Managers (PBMs) continue to benefit from higher drug prices in order to maximize profits.

Think about every major health reform effort over the last several decades: Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP) and the Affordable Care Act (ACA). The successes of each were grounded in patient-centric reforms to our system. Now, as we work toward yet another opportunity for health care reform, dealing with drug pricing has become the major focus. But unlike the successes of the past, the leading drug cost proposals under consideration focus more on government savings rather than patient needs. This is most evident in the House bill H.R.3 and the Senate's S.2543, which call for complete overhauls of our health care system and could undermine the Medicare marketplace.

In the House plan, lawmakers intend to utilize international price setting, which is likely to incorporate value assessments and average prices from foreign countries to determine drug costs and coverage in Medicare Part D as well as private plans. This would be done without input from the physicians who know the most effective treatment options for their patients. Additionally, the Senate Finance Committee's drug pricing package would significantly reduce patient reimbursements for Part B drugs and therapies, which treat chronic conditions such as cancer and autoimmune diseases.

I worry about Medicare recipients who are already protected and happy with their current Medicare coverage. And these bills do little to offer help for patients under 65, do not attack the abuses of insurance companies or Pharmaceutical Benefit Managers and do not seem to address the Medicare beneficiaries’ main concerns with runaway out-of-pocket expenses.

I also worry that this approach is likely to target the newest treatments as those are often the more expensive drug options, reducing access to those medications and therapies that do not abide by the proposals' thresholds. In practice, this would disproportionately impact innovative and breakthrough medications from getting into the hands of patients. We have seen how this works in other countries that have instituted similar care models, with the effects particularly felt by patients living with cancer or rare disorders.

In Medicare, patients should be protected against outrageous out-of-pocket spending and PBMs that pocket savings that could help lower costs at the pharmacy. We need to focus on solutions that directly address these issues. A spending cap in Medicare will limit how much patients pay out-of-pocket for prescription drugs and allow them to better financially plan for other care needs. While an out-of-pocket cap is included in H.R. 3 it doesn’t go far enough to ensure lower out-of-pocket spending for a significant number of beneficiaries. Additionally, reforming the rebate system to require PBMs to share rebates with patients will directly lower drug prices and bring added transparency to the system. Focusing on these patient-centered changes will also improve adherence and lower costs for not only patients but the government as well.

For health care reform to work, we have to directly tackle the problems facing patients. This means improving our rebate system, reducing out-of-pocket expenses in Medicare and maintaining the quality of care. If we can focus on these three issues, can we deliver results that will be immediately felt by patients and improve their health and lives for the better.

Howard Dean is the former Governor of Vermont and a retired physician now working as an independent political consultant.