A Systems Approach To Understanding Insurers' Policies

United Healthcare's Prescription Solutions raised the price of Medicare Part D ezetimibe from approximately $75 in 2008 to approximately $250 in 2009. Unfortunately, because I had already signed up to renew my coverage, before the 2009 formulary with its new stratospheric charges appeared in my mailbox, I had two choices: stop this LDL lowering drug or pay up.

Thinking about this from a systems perspective, I could envision United Healthcare - which the NY Times reported on 1/16/2009 had settled ". . . class-action lawsuits claiming it had underpaid patients and doctors . . . ." doing this for any of several reasons. First, perhaps the price of ezetimibe had tripled, but I wasn't aware that it had. Second, perhaps those taking ezetimibe are a high risk group, and if the United Healthcare's Prescription Solutions did not make available the drug these people needed at an affordable price, they might leave (reducing United Healthcare's MediGap and other coverage risks and Prescription Solution's Risk in a variant cherry-picking arrangement). Third, perhaps Prescription Solutions was using patients treated with ezetimibe as battering rams in negotiating prices with drug manufacturers.

By the way, on January 8, 2009, the FDA concluded that those high risk individuals taking a lipid lowering combination including ezetimibe should not stop taking the medication. . Perhaps United Healthcare was just too busy defending its class action cases and investigations by various state attorney generals to have paid attention to this warning and price its Zetia accordingly.