Jon Cohn does us some good by injecting questions of transparency into the debate on drug tiering. "The fundamental problem here is that we don't know how the insurers make these decisions because they generally don't make them in a public and transparent way," he writes. I'd use a slightly different word: legitimacy. The fundamental problem for insurers right now is that their decisions lack legitimacy. Their business model is a glorified conflict of interest: They make money by not providing care, so it's hard to believe their denials of care are motivated by pure adherence to best treatment practices. And because they don't open up their data, it's impossible to check their decisions against the facts of the case and figure out whether the denial was warranted. The outcome lacks legitimacy, and so it's not trusted, even in a case where insurers are correctly denying care because it's not worth paying for. Insurers, to some degree, know this. They have endorsed independent review boards that could evaluate claim outcomes and render a binding decision. Their hope is that this obviates the need to release the data and creates a higher authority who can be trusted even if the insurance industry isn't seen as a paragon of integrity. They've also endorsed the creation of a national comparative effectiveness review board that would research the efficacy of drugs and produce legitimate research that could be used to set coverage rates. That's a damn good idea, and one of those places where the incentives of the insurance industry align with those of consumers. But both essentially try and create and end run around the public's dislike, and distrust, of the insurance industry. At some point, the fundamental problem of legitimacy and transparency within the sector will have to be addressed. Relatedly, I've e-mailed the folks at AHIP to ask how drugs are chosen for Tier 4 (see previous post). I'll let you know what I hear.
