AIPA President Craig Moore OP-ED

Caring for an aging parent or a sick child is something that we will all succumb to at some point in time in our lives. Today with all the technology, knowledge and resources that we have, one would think that access to affordable healthcare would be available to everyone, but it is not. Why does the greatest country on the face of the earth struggle with access to affordable healthcare. I would like to submit to you today that the answer is greed. Medical decisions are no longer controlled by your physician or the healthcare provider. The decisions are made by insurance companies and accountants that put profits over patients. Many shell games are played within the system. Today, I would like to share my family’s personal story.

Over the last two years, my father has experienced multiple health related issues. He was diagnosed with pulmonary fibrosis. To stop the spreading of the disease, he was prescribed a specialty medication that had to be dispensed by a specialty pharmacy. Going in, we knew that the medication could possibly have side effects, but it is something that my father was willing to try. After a couple of months on the medication, he had to stop taking it because of extreme nausea. After he stopped taking the medicine, the nausea continued and even increased. He developed several infections that were treated with antibiotics, yet the nausea continued to increase to an unbearable level. He lost 25 pounds; he couldn’t leave the house because he could not control the side effects of the nausea. Our family physician, who is not only a fabulous old school doctor, but he is a dear friend as well, suggested that he take an injection that is given to cancer patients that help with nausea. As you might expect, the insurance company said no. Our family owns a pharmacy, so we looked at the cost of the injection and the cost was approximately $45 for a vial. The injections helped but they did not solve the problem. After multiple tests the physician found out that he had an infection in his stomach called c-diff and he had a condition called lymphatic colitis. Our physician told our family that he would need to take an antibiotic called liquid vancomycin. The insurance company refused to cover the medicine the doctor prescribed, and they suggested a medicine that was about $6000. There were several problems with their suggestion:

1. The medicine that they suggested was an expensive brand that was used for metastatic colitis. The net effect is that the medicine would not work because the condition was not metastatic colitis.

2. Why would they suggest the $6K medicine when the medicine the doctor prescribed costs $95 dollars. To be clear, the $6K cost would not have been paid by my father. The plan would have to absorb the cost. Why would an insurance provider steer the patient to a medicine that had such a large price spread? My Alabama math would suggest to me that they would prefer to pay for the cheaper option that the doctor prescribed. So why didn’t they? After all, isn’t it their job to save the plan sponsor money which in this case was the Retirement System of Alabama or PEEHIP.

As I stated earlier, our family owns a pharmacy, and we understand the answers to the questions. We opted to pay cash for the $95 dollar medicine that the doctor prescribed because we trust our doctor over the insurance company. In the end, my father is healing.

So, what are the answers to the questions. Why would the insurance company want to steer the patient to the brand when a generic would work. After all, it’s what the doctor ordered. The answer lies in kickbacks and rebates that the insurance company receives from the drug manufacturer. In this case, if we had dispensed the $6K drug through the insurance, we would have been reimbursed below our cost to obtain the drug. More than likely the prescription would have been sent to a specialty pharmacy where the cost for the drug would have gone up, netting more for the insurance company. Insurance companies own specialty pharmacies, so it is more advantageous for them to do the work themselves. So that was not an option for our family. We opted to follow the medical advice from our doctor and the healthcare professionals involved with his treatment. Most people don’t have the luxury of owning a pharmacy. Most people don’t have the luxury of paying cash and following the “doctor’s orders”. At least that is what you are led to believe.

If you study the Fortune 500, both CVS Health, United Healthcare and Cigna Express Scripts were all listed in the top 20 of the Fortune 500 in 2024. Since I live in Alabama and Blue Cross of Alabama is the predominate player in this state, we do not know what they make because the legislature granted them non – profit and non-disclosure status back in 2012. The largest profit maker for each of these entities is their Pharmacy Benefit Manager businesses. A PBM determines what amount of money a pharmacy will be reimbursed for dispensing a drug. So, you ask why an insurance company would want to dispense an expensive brand over an inexpensive generic, it’s all about the Benjamins”. An insurance company doesn’t care about the patient; they care about the profits. They care about the stock price.

Healthcare stands at a crossroads in Alabama and the country. As you can see in my example, there are significant ways that we can change our system to be more affordable for the citizens and to create better outcomes for the patients. The path that we are on is not sustainable. Currently insurance companies are a major part of the problem. Can they become a major part of the solution? Elected officials are a part of the problem. How so you might ask? Elected officials must put the people over the position? Capped corporate contributions and term limits would be a good start. Special interest and lobbyists are part of the problem. Can they be part of the solution? Probably not.

In closing, would you rather have an accountant perform medical procedures on you or would you rather have a healthcare provider perform procedures on you? I think I can surmise the answer to that question.

About the author – Craig Moore is a former Human Resource Executive with 25 years’ experience managing insurance and benefits for Manufacturing companies. He and his wife Angie own an independent retail pharmacy and he is currently President of the Alabama Independent Pharmacy Alliance, a grassroots movement that was formed in 2024 to advocate solely for Independent Community Pharmacies in Alabama. If you are interested in contacting Craig, you can email him at craig@valleyrxdme.com.