By Dr. Gareth Lema
On Dec. 13, Scott Scanlon wrote a well-researched article in The News about vision-saving drugs for macular degeneration. The rising costs of FDA-approved drugs is incredibly complex and yet an immediate crisis.
However, the problem with Independent Health’s new policy is very simple: It purposefully uses a financial incentive to influence the decision your doctor makes for your care. The most important consequence of this policy is that you cannot trust that your doctor is unbiased, if you subscribe to Independent Health.
If a drug company paid a doctor to use one drug over another it would be considered unethical and illegal. The doctor could lose his or her license and potentially face criminal prosecution.
If you seek legal advice, your lawyer is ethically bound to act in your best interest.
But somehow, it is OK for Independent Health to use a financial penalty to influence your physician to choose an off-label drug based on cost alone, without consideration of best clinical practices.
Independent Health is one of the largest insurers in the region. Most practices cannot afford to stop accepting Independent Health. The fee reduction that Independent Health has proposed could bankrupt small practices. Therefore, any physician that accepts Independent Health will have to consider this policy while deciding which treatment option is best for you.
I do not know if Independent Health intended to harm the relationship you have developed with your doctor. Independent Health is a nonprofit organization, run by knowledgeable physicians who openly pledge to serve their subscribers. I certainly hope that any negative consequences were unexpected. Nonetheless, Independent Health has a responsibility to recognize the faults in this policy and consider options that do not limit your access to the most effective treatment.
The need to develop cost-effective care strategies is well known, and I agree with Independent Health’s goals to encourage value-based medicine. I also firmly believe in two principles. First, clinically relevant best practices cannot be ignored. Second, a third party cannot create a direct financial incentive for physicians to choose one drug over another.
I have written to Independent Health and met with their administrators. I have asked them to openly collaborate with a panel of retina specialists to develop guidelines that are both cost-effective and adhere to clinical best practices. It is now their choice to proceed with a policy that is based on cost alone, or one that also includes clinical criteria. Considering both would create a policy of true value.
Dr. Gareth Lema is a practicing retina specialist and a member of the Board of Directors for the New York State Ophthalmological Society.