OPINION

Opinion: Obscure group helps block patient access to crucial medications

MIAMI, FL - JUNE 28:  Dr. Gregory Coleman, Assistant Professor of Medicine, University of Miami, Miller School of Medicine, speaks with Vanessa Moreno, 25 years old, as she visits him for a check-up  on the same day that the United States Supreme Court upheld the Affordable Care Act on June 28, 2012 in Miami, Florida. Dr. Coleman said, ?the ruling is a good start to begin to control the economics of medicine?.  (Photo by Joe Raedle/Getty Images)

MIAMI, FL - JUNE 28: Dr. Gregory Coleman, Assistant Professor of Medicine, University of Miami, Miller School of Medicine, speaks with Vanessa Moreno, 25 years old, as she visits him for a check-up on the same day that the United States Supreme Court upheld the Affordable Care Act on June 28, 2012 in Miami, Florida. Dr. Coleman said, ?the ruling is a good start to begin to control the economics of medicine?. (Photo by Joe Raedle/Getty Images)  (2012 Getty Images)

When it comes to quality health care, the U.S. Latino population starts out at a serious demographic disadvantage. We are more likely to lack health insurance and face other serious hurdles to accessing quality care.  And the incidence of serious disease is much higher among Hispanics than the American population at large.

ICER’s methodology in determining which drugs are worth the money is reminiscent of the criticisms of the many unelected and unaccountable boards and commissions set up under Obamacare whose mission it is to “keep costs down,” but which in practice play with patient lives by deeming certain treatments and patients to be unworthy.

- Mario H. Lopez

For instance, heart disease is the nation’s No. 1 killer, and among Hispanics, cardiovascular disease is even more pervasive because of heightened risk factors, like high blood pressure, obesity and diabetes.

So it should be considered good news for our community, as well as anyone concerned with public health, that two new drugs for people with very high cholesterol are now available—medicines that reduce cholesterol about twice as much as existing drugs.

But an obscure group called the Institute for Clinical and Economic Review, or ICER, is preventing and bogging down access to these types of medicines for patients in need.

ICER, which is holding a public hearing in Los Angeles tomorrow on programs to prevent diabetes, reviews new drugs that combat serious diseases and then issues “guidance” as to whether insurance companies should cover them.  Those companies are paying close attention ICER recommendations, often to the detriment of patients.

ICER’s methodology in determining which drugs are worth the money is reminiscent of the criticisms of the many unelected and unaccountable boards and commissions set up under Obamacare whose mission it is to “keep costs down,” but which in practice play with patient lives by deeming certain treatments and patients to be unworthy.

This is because ICER relies on “Quality-Adjusted Life Years,” or QALYs, a metric that is commonplace in the United Kingdom, which has a highly criticized system of rationing  medications and treatments. QALYs assign value to a person based on the length and quality of life—the sicker or older you are, the worse your QALY score and the less your life is valued. They are so controversial that even Obamacare banned them under Medicare as part of the much publicized debate on “death panels.”

With this method, ICER generally finds that new lifesaving drugs are too expensive despite their effectiveness, decisions applauded by insurance companies. In the case of the breakthrough cholesterol drugs, ICER recommended that payers require extensive prior authorizations—mountains of bureaucratic paperwork that disincentives doctors from prescribing drugs. The nation’s largest pharmacy benefits manager, Express Scripts, recently ordered this requirement for patients seeking the new drugs.

ICER calls itself “trusted” and “independent,” but according to a report by the Capital Research Center, an investigative think tank, it was founded and continues to be primarily funded by the health insurance industry and similar interests. With ICER, the health insurance industry is funding a group that is giving health insurance companies and Pharmacy Benefit Managers an excuse to exclude drugs from formularies (the lists of drugs they agree to pay for) or, almost as bad, bury the ability to get a drug in paperwork.

In addition to the breakthrough cholesterol drugs, ICER has reviewed drugs for asthma, diabetes and a blood cancer called multiple myeloma, among others. Unsurprisingly, most of the time ICER deems them too expensive. Future reviews will cover liver disease, lung cancer and multiple sclerosis.

Patients and families of patients that suffer from any of these, or other, diseases stand to suffer. Anyone who cares about health care should be aghast that ICER is intervening between a doctor’s decision to prescribe a drug and a patient’s ability to access it, especially in underserved communities. Let’s hope concerned citizens demand answers for these practices, starting with ICER’s Los Angeles public meeting tomorrow.

Mario H. Lopez is President of the Hispanic Leadership Fund, a national advocacy organization that promotes liberty, opportunity and prosperity.

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