A Boring Dystopia

Obviously the insurance company actually dictates your healthcare and the prescriptions you receive, not your doctor. If you have great insurance, more physicians and treatments will be covered. Under insured is just having insurance that doesn’t cover your treatment.

Anytime a drug comes to market, manufacturers need to make sure drugs are covered by insurers. So, pharma companies go out to the “payers” (it’s what’s we call them at work) and vie to get a good position on the payer’s “formulary” (the list of drugs covered by insurance).

In this negotiation, you have things like “prior authorization” where the prescriber needs to make a case to the insurance company before a drug can be prescribed. There’s also different tiers for a class of drugs. This means the payers allow certain drugs to be covered only after a patient steps through other (cheaper) treatments. If it’s not covered, you can pay out of pocket but none of this shit is priced for an individual.

There’s a cold calculus on both sides where the pharma company has sunk $300 million to $5 billion dollars to bring a drug to market that can sometimes take a decade to go through clinical trials and receive FDA approval — they need to charge a lot to recoup their investment and hopefully become profitable. Meanwhile, insurers have a population they need to cover and a set pool of money and they don’t need a new $50,000 therapy when there’s a generic that will treat 80% of patients. The other 20% can jump through the hoops or get stuffed…