The Curse of 'The 90-Day Supply'

I don’t pretend to have all the answers to help solve the "health care crisis," but I am pretty sure I know what will fail, and I don’t think we have a "crisis."

I worry that the false call for urgent reform in 2009 has made everything worse. My favorite way to explain the issue is to consider the fallacy and moral hazard of "the 90-day supply."

The following conversation takes place almost everyday in my office. (I have no reason to believe that I am unique, and I am sure that some form of this conversation takes place in your office, as well.)

A patient presents with a localized patch of dermatitis that requires a brief course of potent topical steroids. A 1-week supply with a single refill is prescribed but the patient requests a "90-day supply."

Although I always know where the conversation is going, I play along.

"You only need 1 week’s worth of the drug, why do you think you need a 90 day supply?"

"Well", the patient explains, "I get the 90-day supply for free. I have to pay a copay for the 1-week supply."

"But you’d be wasting 11 weeks of medicine to save a few dollars," I say.

Invariably, the patients tell me that they don’t care; they’d rather save money. When I inform them that what they’re doing is insurance fraud, they always tell me that "all" of their "other doctors" do it. I have never obliged any of them.

The parable points out the problem with health care when people don’t actually pay for it. It’s called a moral hazard. People behave differently when they bear no risk or responsibility for their actions.

Take corrective laser eye surgery for example. A decade ago, it was thousands of dollars an eye. Today, it runs as low as $199 an eye. Why? Because insurance companies don’t pay for it and the government doesn’t pay for it. People pay for it. The free market works. It makes everything more efficient. Conversely, when people don’t pay for something, I believe they waste and abuse it.

Health care insurance should be for expensive procedures and hospitalizations and should be a lot cheaper. Insurance shouldn’t be for visits to the chiropractor.

If people paid out of pocket, practitioners would be able to streamline their offices, lower overhead, charge less, and see patients more efficiently. Instead, we have a situation that I believe is expensive, inefficient, and capricious.

If people paid for their own health care, they would ask how much an office visit cost and would make sure they were receiving the most efficient care.

In a free-market system, a better physician in a well-run office would be better compensated for better care. Today, insurance companies pay the best physician in New York the same as the worst. Lawyers write these laws, but you can bet your house they all don’t charge the same.

Dr. Goldberg is a member of the editorial advisory board of Skin & Allergy News and practices dermatology in Bronxville, N.Y. Dr. Goldberg’s views are his own and do not necessarily reflect the views of this publication.