Responsibility: Pharmaceutical Regulation of Chronic Disease Among the Poor

This chapter explores the ways in which patients and healthcare providers at a Massachusetts Health Clinic were made accountable through the private sector rationales of:

• Transparency
• Individual Responsibility
• Cost Effectiveness

that are meant to manage chronic disease under healthcare reform.

Problem:

• many of the reforms with ACA went less far than Article 5 Had.
• federal subsidies for low to moderate income were lower under ACA
• Payments to safety net hospitals were lower (Lost 1/2 billion dollars in 10 years)
• Mass. had appealed to the ETHICAL principles of redistributive justice in an effort to get people to buy into article 54
• linked ethical claims and  economic justifications to notions of ACCOUNTABILITY (application of the business model)
• cost control
• transparency
• good business practices
• return on investment

ANTHROPOLOGY OF ACCOUNTABILITY

• the ethical injunction to take responsibility for , or be held responsible for wrongdoing
• the "new managerialism": transparency and cost control
• discipline  and accountancy, financial and human accountability were merged. 
• Neoliberal "privatized actuarialism" 
• apply to your individual private lives the same principles applied to audit corporations and bureaucracies. 
• individual responsibility and risk minimization
• increased burden of documentation and verification

How do poor patients with chronic diseases manage their health considering the contradictory policies of expanded access and cost control?

• Techniques of Cost Control
• bureaucratic disentanglement
• prevents "rights" from being translated into benefits in many cases
• deferral, disinformation, delay in enrollment processes
• Cost control measures ACA
• limited application periods
• slashed number of healthcare guides
• need to re-qualify and reapply each year
• RITUAL OF CERTIFICATION
• All led to a distrust of the medical system

Controlling Pharmaceuticals for the Chronically Ill (techniques)

• Three ways for patients to experience Accountability"
• Changing Formularies
• Constantly changing medications which are paid for by insurance companies or subsidized by the federal government
• third party payers become the locus of cost control (if the govt. does not negotiate, as with drug companies-as with medicare/caid)
• generic drug requirements
• tiered formularies with higher copays for name brand drugs
• associated with decreased compliance in chronically ill patients, and increased emergency room and inpatient care
• disrupted relationships with physicians and familiarity with drug protocols
• different brands may affect patients differently
• physicians may get around this by giving their patients drug samples given to them by the pharmaceutical companies when a drug is no longer preferred.
• dependent of varying supplies
• creates immense insecurity in patients
• lose faith in doctors and their knowledge
• more stringent authorization and review strategies
• better management of small number of high cost medicaid patients and prescription drug benefits
• Transparency-see the cost of their care- their share and the governments
• cost sharing statements served NOT to make assistance recipients feel better, but to stigmatize them because they received assistance.
• meant to foster personal responsibility -- but why? Business model.
• Struggle to pay high out of pocket expenses
• Even those with good insurance had trouble paying for copays for drugs. 32% reported not taking drugs properly because of cost
• depending on who is working, they may get a waiver-unequal application by pharmacies- even though policies were intended to be transparent, but people saw them as arbitrarily applied
• coping strategies
• decide which are the MOST IMPORTANT DRUGS to take and don't take all that they should everyday
• hoarded pills
• share medications with others

Actuarial techniques are indicative of the decline of public trust and increased need for transparency and visibility. has led to tripling of cost of administration

• increased demands for evidentiary support ($$$)
• entail massive time consuming busywork by institutions and providers ($$$)
• ceaseless reviews of performance, productivity, and efficiency ($$$)