SOCIAL LEARNING ABOUT FAIR LIMITS

Pharmacy benefits have become the problem child of healthcare coverage. Rising demand, increased utilization, and surging costs terrified large purchasers even when the economy was good. Limiting access to some drugs, whether through restrictive coverage policies or tiered co-pays, has often been met with patient and clinician resentment and distrust. Placing this problem child in a properly equipped classroom, with appropriate educational tools and processes, can school us all in how to develop, understand, and accept fair limits.

Most public encounters with limit setting in healthcare, both in the United States and abroad, have been episodic and involved big-ticket items. Often, these have featured denials of “last chance” treatments, creating life-and-death dramas. In 2002 in Boston, for example, Belynda Dunn, an HIV-positive patient, was denied a liver transplant by a managed care organization (MCO) on the grounds that it was “experimental” for patients whose immune systems might be compromised. The MCO then contributed to a charity set up to “rescue” Ms. Dunn and others like her from the consequences of reasonable limit setting.

From episodes like this one, the public is likely to draw confused lessons about the necessity and reasonableness of limits to care. From the Dunn case, it would be easy to conclude that there is always a way around denials if one advocates vigorously enough, can point an accusing finger at the “evildoer” who is denying care, and can attract public sympathy.