HMOs aren't keeping my nose cool or wet

For those of us who love to hate the bad guy, the HMOs have put us in an awkward position. Of course, any of us who are on regular medication can tell their own HMO horror stories, whether it's the hefty co-pay for a med that isn't on the HMO cheap list, or not being able to buy more than 30 days' worth, or bouncing from one approval process to another to get medical care. My doctor calls HMOs "venal", a word I haven't heard since Catholic grade school.

As an arthritic dog, I feel insignificant when I think about the HMOs and the drug companies doing battle over me. And "over me" is the operative phrase, because they have risen above us to such a degree that we exist only as an aggregated statistic. The way I look at fleas.

But the outcome of their battle will affect me dramatically. If popular (and expensive) allergy medications become cheap, over-the-counter remedies (as the HMOs want), we'll probably save some money (except for those dogs in the military and federal government, who pay virtually nothing for their prescriptions). I pay a $50 co-pay for a month's worth of Zyrtec that keeps my nose just moist and cool enough so the other dog doesn't jump. If the same 30 pills could cost less over the counter, I would be happy -- for now. But I would also know the drug companies had the rules changed on them in the middle of the game. And regardless of whether we think drug prices are fair, it is not fair to change the rules after a company has made a several hundred million dollar investment. Our deal with them is that they keep spending the money to come up with new drugs, and we agree to pay a lot for them until the patent runs out and they become over-the-counter. (Of course, it's not fair that Canada and all of Western Europe pay far less for the same drugs, giving them a free ride on our research nickel, but I chalk that up to the vagaries of international trade.)

My problem is that I'm uncomfortable with an HMO as an ally. It's like having a pit bull as a lover. You're just not sure he's going to respect you in the morning -- or that evening, for that matter.

We understand the HMOs are not saying that they're fighting this one for the little dog. They're trying to get OTC approval for allergy meds so they can save money. We don't know whether these extra profits will be used to reduce or hold premium rates, or for extra profits. (Actually, I think we do know where the extra money will go - not in our pockets.)

Regardless, the point of all this is that if the drug companies can't make their expected profit, they will be less likely to develop new drugs, because they are in business to make a profit. And, what does this have to do with arthritis, or, as a lot of visitors to CreakyJoints type in on the search engine, "arthritus"?

1. If HMOs can move expensive prescription drugs that millions of people take daily (Zyrtec, for example) to OTC, then we need to expect that they will try to do the same with other popular drugs that millions of people take, like Celebrex, Mobic and Vioxx. Again, we would benefit short-term if OTC prices came down to less than our co-pay, (for me: $50), but with no financial incentive to produce new drugs for the arthritis market, we might all grow older taking the same meds instead of newer formulas with fewer side effects and better pain relief.

2. It is the HMO's job to provide health insurance, and if an HMO structure won't work unless prescription drugs are taken out of the loop, then we need to look at alternative drug delivery and payment scenarios -- not cheat ourselves out of potentially better future meds, and cheat the drug companies out of profits they were counting on. HMOs seem to be enrolled in a wacky business model where costs are always spiraling out of control, and rather than fix the model, they have hit upon another devious way of slashing their costs and improving their profits. They have made blaming others for their business model failure an art. First it was the hospitals for keeping patients too long, then it was the doctors for caring too much, then it was the specialists for not seeing enough patients, then it was procedures that were not covered. Now, it's prescription drugs. HMOs believe we should be paying for our own drugs, viewing hospitals as out-patient facilities only, paying for our own specialists unless, for example, that lump is actually malignant which we don't know until after the biopsy, and, essentially, modifying our medical care as needed so the HMO can make a profit. Some HMOs routinely disallow medical expenses unless the patient complains more than two times. They have limited their liability by convincing lawmakers to make them immune from lawsuits, allowing them to set policy affecting our quality of life with no threat of patient retaliation.

We need to take a close look at Canada and Western Europe to understand alternatives to HMOs, and we need to understand better the profit motivation of HMOs - every dollar they pay in benefits comes right off their bottom line. It is not in their business interest to pay benefits. So, just like the pit bull, they may seem like our friend by bringing us cheaper OTC prices, but they are only thinking of their own needs. Potentially cheaper OTC prices are a non-goal side-effect of their drive to slash their own costs and increase profits.

And, this dog sees that HMOs are not invested in our community. When was the last time you saw an HMO sponsoring a local arthritis event? The answer is, "Never" for me. Although somewhere I hope they have sponsored an event, I don't have to think twice to recall that virtually every drug company has invested in us through educational grants to our foundations, sponsoring our conferences, giving us free samples, educating us, and encouraging us to get better through better relationships with our doctors and by understanding our disease.

The HMOs, clearly unable to survive in the healthiest sector of our economy now that tech has tanked, have made "no" an unhealthy word for us, and a bottom line builder for them. Their latest move to take away prescription drugs is a "no" we can't accept.