Health Care in the Real World (WPost and CJR)

[Guest guest]

Consumers find it hard to determine how much a drug regimen would cost them By

Steve Luxenberg, Monday, April 11, 6:08 PM

My wife and I don't want to add to the nation's financial woes. We understand

why it's important for us to take responsibility for managing our use of the

health-care system, why we should limit ourselves to necessary expenses. Not

only is it in the country's economic interest, it's also in ours: Our health

plan is structured so that any medical excesses come out of our own pockets.

Now here's the $2.5 trillion-a-year question: How can we make wise choices about

how much to spend on health care if we can't easily find out the cost of a

simple medical procedure? It shouldn't require more than a dozen phone calls and

hours of time — not to mention a hunting dog's single-mindedness — to piece

together an accurate estimate for a recommended treatment.

But that's precisely what happened to us in January and February.

If you work in the White House, on Capitol Hill or anywhere in the health-care

industry, which now consumes about 17 percent of the nation's gross domestic

product, perhaps our micro-example brings a little bit of the real world into

the debate. Consider it one citizen's attempt to make a difference.

Our story begins with a diagnosis (osteoporosis) and a choice of what to do

about it. Several years ago, a bone scan revealed that my wife, Jo, had

lost enough density in her spine and hip areas to suggest that she had a

slightly higher risk of fractures than other women of her age (early 60s). It's

a consequence of aging, so she has a lot of company: According to National

Institutes of Health estimates, more than 8 million older women and 2 million

men have bone-density measurements that qualify as osteoporosis, with millions

more heading in that direction. The NIH attributes 1.5 million fractures

annually to weakened bones.

For years, Jo had been taking daily calcium supplements and Vitamin D, but

our family doctor wanted to do more. She prescribed Fosamax, a once-a-week

tablet that can help slow or halt bone loss. It has since become available in

its generic form, alendronate sodium.

The current cost to us under our insurance plan's pharmacy benefits for generic

drugs: $80 annually. A bargain, if it worked.

Jo wasn't keen on signing up to take a medication for the rest of her life.

In the end, though, she decided to give it a try.

Mixed results

The regimen for alendronate sodium is trickier than for many other drugs. You

not only have to remember to take the pill on the same day each week, but it

must be swallowed whole on an empty stomach, first thing in the morning, with at

least six to eight ounces of water. For 30 minutes after consumption, no lying

down or eating. The worry: damage to tissue in the esophagus on the way down.

For the same reason, the pill cannot be chewed.

Not exactly a user-friendly routine for a weekday work morning. Jo chose

Sunday as swallowing day, a schedule she kept for the next four years.

Her subsequent bone scans yielded mixed results. At best, the treatment was

slowing the decline. At worst, it wasn't having much effect.

When her most recent scan came back with the same ambiguous results except for

one of her hip numbers, she began questioning the medication's value for her, in

part because she had been wondering whether it was a contributing factor to

several months of on-again, off-again gastric distress. But it was hard to know

whether the drug was working without stopping it entirely, waiting a year and

then comparing her next scan with previous ones.

Our family doctor wanted Jo to consult a specialist before making a

decision. The specialist agreed that her density numbers could be better and

suggested a newer medication that she thought might be more effective: Reclast,

approved by the Food and Drug Administration since Jo's original diagnosis.

Reclast also offered a major practical advantage: It is given just once a year,

by intravenous infusion, typically at a hospital's outpatient clinic. It takes

15 to 30 minutes and, as with any medication, there are risks. Before the

injection, blood tests are required to make sure the patient's kidneys are not

vulnerable to damage, one of the nastier possible side effects.

Once a year vs. once a week? Worth exploring, certainly. One big question: How

much more than $80 a year would this trade-off cost?

The quick answer: No one could tell us.

Financial incentives

Almost without exception, everyone we asked — at the doctor's office, the

hospital financial office, the infusion center, our insurance company and the

" Reclast Patient Support Network " (at the drug's maker, Novartis) — was

unfailingly patient and willing to help. What they lacked was clarity. Either

they didn't know the answer and had to refer us to another office, or what they

told us turned out to be incomplete and, occasionally, incorrect.

The infusion center informed us, twice, that the total cost would be $300.

" That's everything, " we were told.

No hospital charge? Nothing for overhead, administration?

" No, that's it, " was the reply. " There's no extra charge for a doctor. We do it

all here. "

We didn't want to be surprised by a big bill at the end, so Jo kept making

phone calls while we awaited our insurance company's pre-certification to

proceed. We're insured through one of Aetna's " consumer-directed health plans, "

the Aetna HealthFund. In recent years, private employers have embraced these

plans as a way to cut rising costs.

It works like this: At the beginning of each year, we receive a set amount ($750

each for 2011) in our account, and we're responsible for paying our medical and

pharmacy bills from that $1,500 until it is exhausted. (We also pay a hefty

monthly premium.)

If we stay within Aetna's network of providers, we pay less — because Aetna has

negotiated deals with providers for each type of charge. In other words, the

insurers and providers know precisely what every procedure costs. Only consumers

remain in the dark.

Once the HealthFund is depleted, we're responsible for 100 percent of most

charges (excluding hospitalization) until we satisfy one of our deductibles,

which is $3,500 each or $4,750 combined. After that, a co-pay arrangement kicks

in, until we reach our $6,000 out-of-pocket maximum. At that point, the plan

covers all expenses. As you can see, it's very much in our economic interest to

hold down what we spend.

In early February, Aetna approved the infusion. The next day, we got a surprise

phone call.

" Hi, I'm from the Aetna Specialty Pharmacy, " the caller said. " We're ready to

ship your medication. " He wanted to confirm the address on his order form.

It was our home address.

" Whoa, " I said. " No one had told us that the medication would come here. Does it

need to be refrigerated? Why would you send it to our house? " I had assumed the

medication was included in the infusion center's " that's everything " package.

Now it was the Aetna caller's turn to be confused. We agreed that his first move

should be to check with the infusion center and the specialist.

" Just out of curiosity, " I said, " how much does the medication cost? "

Silence while he looked. " $1,113.20, " he replied.

I made a noise that might have sounded like a gasp.

" Don't worry, " he said, cheerfully. " It's covered 100 percent. "

I was dubious. I said, " We were told this isn't covered as a pharmacy benefit,

because the infusion is considered a medical procedure. If that's right, then we

will pay all the costs out of our HealthFund. " I went on to explain that the

$1,113 plus the $300 infusion-center charge would wipe out our $1,500 for the

year.

He said he didn't know what would be covered. His job was to check on sending

out the medication. Compartmentalization. He wasn't the first person to tell us

something incomplete, and he wouldn't be the last.

The rest of the story

Our skepticism now justified, we intensified our efforts to pin down the exact

cost. Another round of phone calls produced more conflicting information. One

thing we learned for sure: The infusion center would order Reclast from the

hospital pharmacy, and it would cost $200 more than the Aetna Pharmacy price.

Why didn't our earlier phone calls elicit this information? Again,

compartmentalization: The infusion center wouldn't be billing us for the

Reclast, therefore it wasn't factored into the $300 price. We learned this from

the hospital's financial center.

That prompted another call to Aetna, to see if the hospital could submit the

Reclast order as a pharmacy charge. My argument: When I typed " Reclast " into

Aetna's " Price-a-Drug " online cost calculator, the digital estimator treated it

as a covered expense under our plan. Cost: $70.

No such luck. We would be on the hook for the entire $1,300, the Aetna

representative said, because a Reclast infusion was considered a medical

procedure.

That made the decision easy. Weighing the $1,600 cost vs. the likely benefits,

Jo opted not to go ahead. She also decided to go a year without any

medication. She would keep to her routine of calcium and Vitamin D supplements,

weight-bearing exercises and good diet, and then see what her next scan showed.

Making health-care choices isn't easy, particularly when it comes to such

intangible benefits as reducing a risk that's already hard to quantify.

Ambiguity comes with the terrain — which is why the health-care system shouldn't

add to the confusion.

Of course, it's hard to predict every eventuality. A surgery estimated at two

hours could turn out to be much longer if complications arise. But Jo and I

weren't asking for a guaranteed price, just the basic one. Yes, insurance plans

vary, but aren't computers good at storing data, sorting it out and calculating

bottom lines?

The medical world does not have the equivalent of a restaurant menu or an auto

mechanic's estimate. You might scoff at comparing health care to eating out or

fixing a car, but think about it: If we consumers are expected to take charge of

our health care, we need a one-stop place to find out the itemized cost of

various choices. Otherwise, the idea of " consumer-directed health care " is

little more than euphemistic pretense.

That's hardly what the doctor ordered.

http://www.washingtonpost.com/national/health/consumers-find-it-hard-to-determin\

e-how-much-a-drug-regimen-would-cost-them/2011/03/02/AF2babMD_story.html

Health Care in the Real World

A lesson for the fuzzy-headed bureaucrats—and for the press

By Trudy Lieberman

Steve Luxenberg, an associate editor at The Washington Post, gives a different

twist on covering high-deductible health plans, that new genre of health

insurance that we hope journos—and their editors—will see fit to report on from

time to time. Last week Campaign Desk singled out some interesting political

reporting on these policies, including a good piece from WBUR, which told of a

young man who found that a relatively simple procedure would cost far more than

his insurer's handy-dandy cost calculator had suggested. Luxenberg takes the

story of unpleasant surprises even further, suggesting that high-deductible

plans aren't the great health care saviors policymakers have proclaimed them to

be.

Luxenberg's wife has osteoporosis and had been taking a generic version of

Fosamax for the bargain basement price of $80 a year. At best, the drug was

slowing the loss of bone; at worst, it wasn't having much effect, Luxenberg

wrote. So her doctor recommended Reclast, a newer drug she hoped might be more

effective. That's when the financial fun and games began. Luxenberg has a

consumer-directed plan, aka high-deductible insurance, from Aetna. He and his

wife had $1500 in their Aetna HealthFund to pay the little stuff. Special

savings accounts are often part of these deals. After that, the family had to

meet a $4750 deductible or a $3500 deductible per person. Once they do that,

then they pay copayments until they reach a $6000 out-of-pocket maximum. Then

and only then does Aetna pay all expenses. If the family chose in-network

doctors, they would pay less, but they really wouldn't know what each procedure

would cost. " Insurers and providers know precisely what every procedure costs.

Only consumers remain in the dark, " Luxenberg reported.

Because the family is on the hook for so much out-of-pocket dough, the price of

a new treatment is important. However, they found that price shopping is a

figment of the marketplace imagination, not a practical option for choosing

medical care. Luxenberg and his wife wanted to know how much more the new drug

would cost than the $80 they were spending for generic Fosamax. The quick

answer, Luxenberg told his readers, was " no one could tell us. " While everyone

they asked—from the doctor's office to the drug maker's support network—was nice

and willing to help, their answers lacked " clarity. " Sometimes they didn't know

the answer and referred the family to another office. Sometimes what they were

told turned out to be incomplete, and occasionally incorrect.

Like Matt S. in the WBUR story, who got a low-ball price from his insurer's

calculator, Luxenberg got one too. He used Aetna's " Price-a-Drug " online

calculator that estimated the price for the drug. Since it was a covered

expense, it was expected to cost only $70. Finally, they got some real numbers

from an Aetna representative. The price each month would be $1300 plus $300 for

the infusion center's charge.

Weighing the higher price and likely benefits, Luxenberg's wife said " forget

it. " She decided not to take Reclast or generic Fosamax and instead go with

calcium, Vitamin D supplements, and weight-bearing exercises for a year and see

what happens. Luxenberg concluded: " If we consumers are expected to take charge

of our health care, we need a one-stop place to find out the itemized cost of

various choices. Otherwise, the idea of `consumer-directed health care' is

little more than euphemistic pretense. "

The Post's story is important because it keeps public conversation going on this

most important of topics.

http://www.cjr.org/campaign_desk/health_care_in_the_real_world.php

[Guest guest]

This man's health insurance plan sounds like it sucks big time. Patients should protest loud and long at getting the run-around this man and his wife got. Every hospital knows what procedures and medications cost. If they did not know the cost they would not be able to bill people. The secret here is for the patient to be insistent until as satisfactory answer free of flim-flam is given. I am fortunate to have very good insurance.

Fall down six times; stand up seven.

Japanese proberb

From: rumjal <rumjal@...>Flu Sent: Thu, April 14, 2011 10:52:57 PMSubject: [Flu] Health Care in the Real World (WPost and CJR)

Consumers find it hard to determine how much a drug regimen would cost them By Steve Luxenberg, Monday, April 11, 6:08 PMMy wife and I don't want to add to the nation's financial woes. We understand why it's important for us to take responsibility for managing our use of the health-care system, why we should limit ourselves to necessary expenses. Not only is it in the country's economic interest, it's also in ours: Our health plan is structured so that any medical excesses come out of our own pockets.Now here's the $2.5 trillion-a-year question: How can we make wise choices about how much to spend on health care if we can't easily find out the cost of a simple medical procedure? It shouldn't require more than a dozen phone calls and hours of time — not to mention a hunting dog's single-mindedness — to piece together an accurate estimate for a recommended treatment.But that's precisely what happened to us in January and

February.If you work in the White House, on Capitol Hill or anywhere in the health-care industry, which now consumes about 17 percent of the nation's gross domestic product, perhaps our micro-example brings a little bit of the real world into the debate. Consider it one citizen's attempt to make a difference.Our story begins with a diagnosis (osteoporosis) and a choice of what to do about it. Several years ago, a bone scan revealed that my wife, Jo, had lost enough density in her spine and hip areas to suggest that she had a slightly higher risk of fractures than other women of her age (early 60s). It's a consequence of aging, so she has a lot of company: According to National Institutes of Health estimates, more than 8 million older women and 2 million men have bone-density measurements that qualify as osteoporosis, with millions more heading in that direction. The NIH attributes 1.5 million fractures annually to weakened

bones.For years, Jo had been taking daily calcium supplements and Vitamin D, but our family doctor wanted to do more. She prescribed Fosamax, a once-a-week tablet that can help slow or halt bone loss. It has since become available in its generic form, alendronate sodium.The current cost to us under our insurance plan's pharmacy benefits for generic drugs: $80 annually. A bargain, if it worked. Jo wasn't keen on signing up to take a medication for the rest of her life. In the end, though, she decided to give it a try.Mixed results The regimen for alendronate sodium is trickier than for many other drugs. You not only have to remember to take the pill on the same day each week, but it must be swallowed whole on an empty stomach, first thing in the morning, with at least six to eight ounces of water. For 30 minutes after consumption, no lying down or eating. The worry: damage to tissue in the esophagus on the way

down. For the same reason, the pill cannot be chewed.Not exactly a user-friendly routine for a weekday work morning. Jo chose Sunday as swallowing day, a schedule she kept for the next four years.Her subsequent bone scans yielded mixed results. At best, the treatment was slowing the decline. At worst, it wasn't having much effect.When her most recent scan came back with the same ambiguous results except for one of her hip numbers, she began questioning the medication's value for her, in part because she had been wondering whether it was a contributing factor to several months of on-again, off-again gastric distress. But it was hard to know whether the drug was working without stopping it entirely, waiting a year and then comparing her next scan with previous ones.Our family doctor wanted Jo to consult a specialist before making a decision. The specialist agreed that her density numbers could be better and

suggested a newer medication that she thought might be more effective: Reclast, approved by the Food and Drug Administration since Jo's original diagnosis.Reclast also offered a major practical advantage: It is given just once a year, by intravenous infusion, typically at a hospital's outpatient clinic. It takes 15 to 30 minutes and, as with any medication, there are risks. Before the injection, blood tests are required to make sure the patient's kidneys are not vulnerable to damage, one of the nastier possible side effects.Once a year vs. once a week? Worth exploring, certainly. One big question: How much more than $80 a year would this trade-off cost?The quick answer: No one could tell us.Financial incentivesAlmost without exception, everyone we asked — at the doctor's office, the hospital financial office, the infusion center, our insurance company and the "Reclast Patient Support Network" (at the drug's

maker, Novartis) — was unfailingly patient and willing to help. What they lacked was clarity. Either they didn't know the answer and had to refer us to another office, or what they told us turned out to be incomplete and, occasionally, incorrect.The infusion center informed us, twice, that the total cost would be $300. "That's everything," we were told.No hospital charge? Nothing for overhead, administration?"No, that's it," was the reply. "There's no extra charge for a doctor. We do it all here."We didn't want to be surprised by a big bill at the end, so Jo kept making phone calls while we awaited our insurance company's pre-certification to proceed. We're insured through one of Aetna's "consumer-directed health plans," the Aetna HealthFund. In recent years, private employers have embraced these plans as a way to cut rising costs.It works like this: At the beginning of each year, we receive a set amount

($750 each for 2011) in our account, and we're responsible for paying our medical and pharmacy bills from that $1,500 until it is exhausted. (We also pay a hefty monthly premium.)If we stay within Aetna's network of providers, we pay less — because Aetna has negotiated deals with providers for each type of charge. In other words, the insurers and providers know precisely what every procedure costs. Only consumers remain in the dark.Once the HealthFund is depleted, we're responsible for 100 percent of most charges (excluding hospitalization) until we satisfy one of our deductibles, which is $3,500 each or $4,750 combined. After that, a co-pay arrangement kicks in, until we reach our $6,000 out-of-pocket maximum. At that point, the plan covers all expenses. As you can see, it's very much in our economic interest to hold down what we spend.In early February, Aetna approved the infusion. The next day, we got a surprise phone

call."Hi, I'm from the Aetna Specialty Pharmacy," the caller said. "We're ready to ship your medication." He wanted to confirm the address on his order form.It was our home address."Whoa," I said. "No one had told us that the medication would come here. Does it need to be refrigerated? Why would you send it to our house?" I had assumed the medication was included in the infusion center's "that's everything" package.Now it was the Aetna caller's turn to be confused. We agreed that his first move should be to check with the infusion center and the specialist."Just out of curiosity," I said, "how much does the medication cost?"Silence while he looked. "$1,113.20," he replied.I made a noise that might have sounded like a gasp."Don't worry," he said, cheerfully. "It's covered 100 percent."I was dubious. I said, "We were told this isn't covered as a pharmacy benefit, because the infusion

is considered a medical procedure. If that's right, then we will pay all the costs out of our HealthFund." I went on to explain that the $1,113 plus the $300 infusion-center charge would wipe out our $1,500 for the year.He said he didn't know what would be covered. His job was to check on sending out the medication. Compartmentalization. He wasn't the first person to tell us something incomplete, and he wouldn't be the last.The rest of the storyOur skepticism now justified, we intensified our efforts to pin down the exact cost. Another round of phone calls produced more conflicting information. One thing we learned for sure: The infusion center would order Reclast from the hospital pharmacy, and it would cost $200 more than the Aetna Pharmacy price.Why didn't our earlier phone calls elicit this information? Again, compartmentalization: The infusion center wouldn't be billing us for the Reclast, therefore it wasn't

factored into the $300 price. We learned this from the hospital's financial center.That prompted another call to Aetna, to see if the hospital could submit the Reclast order as a pharmacy charge. My argument: When I typed "Reclast" into Aetna's "Price-a-Drug" online cost calculator, the digital estimator treated it as a covered expense under our plan. Cost: $70.No such luck. We would be on the hook for the entire $1,300, the Aetna representative said, because a Reclast infusion was considered a medical procedure.That made the decision easy. Weighing the $1,600 cost vs. the likely benefits, Jo opted not to go ahead. She also decided to go a year without any medication. She would keep to her routine of calcium and Vitamin D supplements, weight-bearing exercises and good diet, and then see what her next scan showed.Making health-care choices isn't easy, particularly when it comes to such intangible benefits as reducing

a risk that's already hard to quantify. Ambiguity comes with the terrain — which is why the health-care system shouldn't add to the confusion.Of course, it's hard to predict every eventuality. A surgery estimated at two hours could turn out to be much longer if complications arise. But Jo and I weren't asking for a guaranteed price, just the basic one. Yes, insurance plans vary, but aren't computers good at storing data, sorting it out and calculating bottom lines?The medical world does not have the equivalent of a restaurant menu or an auto mechanic's estimate. You might scoff at comparing health care to eating out or fixing a car, but think about it: If we consumers are expected to take charge of our health care, we need a one-stop place to find out the itemized cost of various choices. Otherwise, the idea of "consumer-directed health care" is little more than euphemistic pretense.That's hardly what the doctor

ordered.http://www.washingtonpost.com/national/health/consumers-find-it-hard-to-determine-how-much-a-drug-regimen-would-cost-them/2011/03/02/AF2babMD_story.htmlHealth Care in the Real WorldA lesson for the fuzzy-headed bureaucrats—and for the pressBy Trudy LiebermanSteve Luxenberg, an associate editor at The Washington Post, gives a different twist on covering high-deductible health plans, that new genre of health insurance that we hope journos—and their editors—will see fit to report on from time to time. Last week Campaign Desk singled out some interesting political reporting on these policies, including a good piece from WBUR, which told of a young man who found that a relatively simple procedure would cost far more than his insurer's handy-dandy cost calculator had suggested. Luxenberg takes the story of unpleasant surprises even further, suggesting that high-deductible plans aren't the great health care saviors

policymakers have proclaimed them to be.Luxenberg's wife has osteoporosis and had been taking a generic version of Fosamax for the bargain basement price of $80 a year. At best, the drug was slowing the loss of bone; at worst, it wasn't having much effect, Luxenberg wrote. So her doctor recommended Reclast, a newer drug she hoped might be more effective. That's when the financial fun and games began. Luxenberg has a consumer-directed plan, aka high-deductible insurance, from Aetna. He and his wife had $1500 in their Aetna HealthFund to pay the little stuff. Special savings accounts are often part of these deals. After that, the family had to meet a $4750 deductible or a $3500 deductible per person. Once they do that, then they pay copayments until they reach a $6000 out-of-pocket maximum. Then and only then does Aetna pay all expenses. If the family chose in-network doctors, they would pay less, but they really wouldn't know what each procedure

would cost. "Insurers and providers know precisely what every procedure costs. Only consumers remain in the dark," Luxenberg reported.Because the family is on the hook for so much out-of-pocket dough, the price of a new treatment is important. However, they found that price shopping is a figment of the marketplace imagination, not a practical option for choosing medical care. Luxenberg and his wife wanted to know how much more the new drug would cost than the $80 they were spending for generic Fosamax. The quick answer, Luxenberg told his readers, was "no one could tell us." While everyone they asked—from the doctor's office to the drug maker's support network—was nice and willing to help, their answers lacked "clarity." Sometimes they didn't know the answer and referred the family to another office. Sometimes what they were told turned out to be incomplete, and occasionally incorrect.Like Matt S. in the WBUR story, who got a

low-ball price from his insurer's calculator, Luxenberg got one too. He used Aetna's "Price-a-Drug" online calculator that estimated the price for the drug. Since it was a covered expense, it was expected to cost only $70. Finally, they got some real numbers from an Aetna representative. The price each month would be $1300 plus $300 for the infusion center's charge.Weighing the higher price and likely benefits, Luxenberg's wife said "forget it." She decided not to take Reclast or generic Fosamax and instead go with calcium, Vitamin D supplements, and weight-bearing exercises for a year and see what happens. Luxenberg concluded: "If we consumers are expected to take charge of our health care, we need a one-stop place to find out the itemized cost of various choices. Otherwise, the idea of `consumer-directed health care' is little more than euphemistic pretense."The Post's story is important because it keeps public conversation going on

this most important of topics.http://www.cjr.org/campaign_desk/health_care_in_the_real_world.php