Author Topic: 98% Savings (Unbreaking the Broken Medical System)  (Read 2343 times)

BicycleB

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98% Savings (Unbreaking the Broken Medical System)
« on: January 22, 2019, 06:43:22 PM »
Non-US readers, yes you may take this as trifling comedy.

Last night I was surprised to discover a gently weeping sore on a delicate area of my skin. Ask not the location details, let's move on. Never having experienced such a thing before, I arrived at Doctor UrgentCare's office today in due course. Due course meaning after trying to convince my new ACA insurer that "<BigMedicalCompany TownFarAway>" cannot possibly named as my primary care physician because it's not a person's name. Doctor UrgentCare identified the sore as a fungal infection and duly transmitted a prescription to my pharmacy of choice.

At the pharmacy, Pharmacy Tech informed me that my insurance company doesn't cover the prescribed item, but I can buy it directly. "How much is it?" Clouds part, thunder rolls. "$418." My eyebrows rise above the clouds.

I feel ever so wise for having hustled to the pharmacy, because the time was 15 minutes prior to the closing time of UrgentCare Office. Having noted Dr. UrgentCare's name, miraculously I got her on the phone before closing. Astonished at the price, she responded that "any antifungal powder should do" and advised having the pharmacy just sell me some over the counter. Just as miraculously in my eyes, Pharmacy Tech promptly called Pharmacist into the case, and Pharmacist quickly walked me to aisle where exactly one antifungal powder was for sale. Price: $5.98 plus tax, aka $6.47... a savings of over 98%.

Badass? Maybe not, really. But I guess one of the skills needed in USA right now is how to overcome the craziness of medical pricing, such as $418 charges for $6 items.

Stories and comments welcome.
« Last Edit: January 22, 2019, 06:48:54 PM by BicycleB »

ThatGuy

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #1 on: January 22, 2019, 09:36:58 PM »
You should check the price of the prescription on healthwarehouse.com and the app GoodRx.  It would be interesting to see if it's available cheaper somewhere else.

Mtngrl

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #2 on: January 23, 2019, 08:23:06 AM »
I have found that physicians rarely have any idea what the drugs they prescribe cost. More than once I have balked at paying for a prescription, only to have an experience very similar to yours -- either I was told to use something OTC, or a second, much less expensive medication was prescribed. My take is that pharmacy reps sell the doctors on using the 'latest and greatest' and that is what sticks in their heads.

hgjjgkj

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #3 on: January 23, 2019, 02:16:25 PM »
What an utterly broken system

ClusterMC

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #4 on: January 26, 2019, 01:44:49 AM »
May I ask what the name of the expensive medication is and the name of the cheap medication?

BicycleB

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #5 on: January 26, 2019, 12:06:05 PM »
No idea, and Lotrimin (miconazole nitrate 2%)

scantee

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #6 on: January 26, 2019, 12:10:58 PM »
Imagine the deprivation people from other countries must feel that they donít even get the option to pay $418 for Lotrimin.

CindyBS

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #7 on: January 26, 2019, 03:29:03 PM »
I don't have dollar amounts, but have had similar experiences with a few drugs.

One was not covered because it was insanely expensive (more than $10K per month) and required our doctor to jump through multiple hoops and bitch slap someone at the insurance company.

But we had a handful of others not covered for basically the reason OP listed.  It or something very similar is available OTC.  One was Lidocaine 4% (sold OTC as Aspercreme)  then some acne wash thing - the Rx was for 1% more active ingredient than what the OTC was and then the equivalent of an age spot remover - Rx was $165, OTC $22. 

I recommend anyone ask a Pharmacist before paying for these types of things when not covered by insurance.  They are very familiar with what is out on the OTC shelves in the aisles, and if not, I find they are more than happy to come out from the desk and look at options with you. 

Much Fishing to Do

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #8 on: January 27, 2019, 01:27:28 PM »
My sister-in-law came to me with her $10k hospital bill asking if I could help (I'm an attorney, I guess thats why she approached me though I knew little about this stuff professionally).

I looked at her insurance thru her husband which looked really good, and knowing this hospital visit was initiated thru a ER visit, was surprised it was denied completely (I know from my own personal experiences well all the crap like insurance companies deciding what you were charged was 'unreasonable' and therefore they will not pay (no crap its unreasonable, thats the only reason I have health insurance in the first place))

Reading thru all the policies and the bills, it didnt make sense.  I wrote a letter on her behalf challenging the denial and copying many entities.  I go t a reply that said she owed nothing as long as I dropped my challenge.

So I dropped my challenge and she owed zero.

WTF?  So most people, who would have paid the bill at once, or paid the bill over time slowly, or ignored the bill as they knew they couldn't pay it, would have been screwed?

How broken is this system that they can just give a college try at getting 10 grand from you and if you call them on it then they accept you really owe them zero and you are supposed to be happy about that instead of realizing that they just tried to scam you out of 10 grand?

Arbitrage

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #9 on: January 28, 2019, 08:39:01 AM »
DW just went through a month+ long fight with a hospital and two insurance companies.  I don't want to go into all of the gory details, but basically the secondary insurance mistakenly billed a procedure as though it was the primary insurance.  Hospital took the EOB that it liked better/said we owed more (the EOB from the secondary insurance), even though it had been paid by both companies, and balance billed us. 

We were threatened multiple times by the hospital, but eventually DW got a very cooperative service rep from the secondary insurance who kept at it, through very unprofessional behavior by the hospital - they would hang up on conference calls when they heard something they didn't like.  Once it became clear what the issue was and the insurance company noted that what the hospital was doing was illegal and would have to be referred to their legal team, the hospital again hung up on the call abruptly, but mysteriously the bill disappeared.  Hospital claimed, "oh, I guess we must've gotten your balance paid by the other insurance company."

Teeth-grindingly frustrating, but luckily for us, DW has a law degree and also used to work in medical billing.  We know that the hospital would get away with this in 99% of cases.  The eventual savings was in no way worth the time she spent on it, but it definitely became a matter of principle.

DadJokes

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #10 on: January 28, 2019, 09:59:13 AM »
Not trying to turn this into a political post by any means, but it certainly is a broken system when the doctors and patients don't know what the cost of medical care or prescription drugs are until after the fact. Transparency of costs would do a lot to mend our system without any sort of major overhaul.

Good on you for finding an alternative.

thesis

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #11 on: January 30, 2019, 12:19:06 PM »
That's badass in my book.

I wonder if there may be something in the human mind where people ascribe greater value to a prescription than something over-the-counter because of its perceived "authority". I haven't had a prescription in ages, but I'm willing to suspect that the whole prescription system is exploited because people are often willing to pay so much more for that sense of authority, not unlike buying "name brands". I'm sure sometimes it is necessary, but I'm curious how many of those prescriptions really are.

Abe

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #12 on: January 30, 2019, 08:36:58 PM »
Before generic medications are sold in the US, they have to be shown to be equivalent to the name-brand medication in terms of active ingredient, purity, and absorption. Almost all conventional (excluding certain antibodies and chemotherapy drugs) have at least one generic that is in the same class. The problem for the drug companies is that you can't "name brand" something that's already generic, and thus can't get a lot of money for it.

What many companies have been doing for several decades now is just modifying pre-existing drugs slightly, proving they act just as well as the cheaper generic, and then marketing it for much more. There may be slight differences in the drug's efficacy, but rarely enough to justify paying several times more. They get around that annoying fact by convincing certain insurance companies to allow only their drug, through some opaque process both refuse to disclose because "trade secrets". A good example of this are the "statins" for cholesterol management.

NY Times recently reported on how drug companies and insurance companies keep playing musical chairs with insulin formulations to keep prices unnecessarily high, forcing patients to change insulin regimens every few months.

Main point of that rambling is...there's almost always something cheaper that's nearly as good.

soccerluvof4

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #13 on: January 31, 2019, 08:06:59 AM »
The fact that we as consumer even have to look around for better deals when it comes to Healthcare in itself is whats one of the many things that is so wrong with the system.

BicycleB

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #14 on: January 31, 2019, 05:35:34 PM »

What many companies have been doing for several decades now is just modifying pre-existing drugs slightly, proving they act just as well as the cheaper generic, and then marketing it for much more. There may be slight differences in the drug's efficacy, but rarely enough to justify paying several times more. They get around that annoying fact by convincing certain insurance companies to allow only their drug, through some opaque process both refuse to disclose because "trade secrets". A good example of this are the "statins" for cholesterol management.

Are statins in general the expensive version?

If so, what is the cheap drug?

If not - I guess some statins are cheap, others expensive?

Motivated questions - old enough that doctors flirt with recommending statins despite my blood pressure being low. Thanks!

Abe

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #15 on: January 31, 2019, 09:52:37 PM »

What many companies have been doing for several decades now is just modifying pre-existing drugs slightly, proving they act just as well as the cheaper generic, and then marketing it for much more. There may be slight differences in the drug's efficacy, but rarely enough to justify paying several times more. They get around that annoying fact by convincing certain insurance companies to allow only their drug, through some opaque process both refuse to disclose because "trade secrets". A good example of this are the "statins" for cholesterol management.

Are statins in general the expensive version?

If so, what is the cheap drug?

If not - I guess some statins are cheap, others expensive?

Motivated questions - old enough that doctors flirt with recommending statins despite my blood pressure being low. Thanks!

Statins are a class of drugs that lower cholesterol. There are a couple different ones with varying strengths. The generic brands charge around $10 per month. There are name brand ones but I would be surprised if anyone prescribed them to you (most have been generic for more than 5 years). Whether you need statins or not depend on your cholesterol level, and this can be high even if your blood pressure is not. They are related but not directly.

TomTX

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #16 on: February 02, 2019, 02:02:46 PM »
I have found that physicians rarely have any idea what the drugs they prescribe cost. More than once I have balked at paying for a prescription, only to have an experience very similar to yours -- either I was told to use something OTC, or a second, much less expensive medication was prescribed. My take is that pharmacy reps sell the doctors on using the 'latest and greatest' and that is what sticks in their heads.

Yep. There is a complete disconnect.

I'm fearing the billing from my recent ER visit. Physically, everything turned out fine. Financially - may be in for a fight.

Abe

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #17 on: February 04, 2019, 08:14:17 PM »
A lot of times we don't know what the exact cost to the patient will be due to insurance agreements, etc. The costs are as opaque to us as they are to you (until the pharmacy tells us both!). The good thing is newer electronic records at least let us know if the insurance company prefers one drug vs the other (Tier 1, etc). Prices can still vary greatly, and medications are added or removed from preferred lists all the time. Unfortunately, that's all they are willing to tell us until after the prescription is ordered. My guess is they probably adjust these lists depending on demand, and if a medication is prescribed a lot, they increase the costs to the patient by kicking it off the preferred list.

One example is Lovenox, which is an injectable blood thinner we give to cancer patients after surgery to avoid blood clots. When it first came out, the cost to the patient was well over $500 for the month course on some insurance, and $30 for others. No real rhyme or reason that I could figure out. As a result, we had to get prior approval to prescribe it, even though it had been shown in well-done trials to reduce the risk of major complications. Now, almost all insurance companies cover it (probably because they finally did a cost analysis and realized it saved money), but prices still vary from $0 to $100.

It'd be helpful if the companies would just tell us when we're choosing from medications. But then we'd have knowledge, and insurance companies don't like it when other stakeholders in our healthcare system (or their competitors) know their hand. The whole system is dumb and a waste of all our time.
« Last Edit: February 04, 2019, 08:26:34 PM by Abe »

BTDretire

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #18 on: February 11, 2019, 05:36:57 PM »
My sister-in-law came to me with her $10k hospital bill asking if I could help (I'm an attorney, I guess thats why she approached me though I knew little about this stuff professionally).

I looked at her insurance thru her husband which looked really good, and knowing this hospital visit was initiated thru a ER visit, was surprised it was denied completely (I know from my own personal experiences well all the crap like insurance companies deciding what you were charged was 'unreasonable' and therefore they will not pay (no crap its unreasonable, thats the only reason I have health insurance in the first place))

Reading thru all the policies and the bills, it didnt make sense.  I wrote a letter on her behalf challenging the denial and copying many entities.  I go t a reply that said she owed nothing as long as I dropped my challenge.

So I dropped my challenge and she owed zero.


  Please give us a clue on what was said in that letter, I know just that it was from an attorney
was probably a key motivator tho the insurance company, but I'm still curious.

Missy B

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #19 on: February 14, 2019, 03:32:56 PM »
That's badass in my book.

I wonder if there may be something in the human mind where people ascribe greater value to a prescription than something over-the-counter because of its perceived "authority". I haven't had a prescription in ages, but I'm willing to suspect that the whole prescription system is exploited because people are often willing to pay so much more for that sense of authority, not unlike buying "name brands". I'm sure sometimes it is necessary, but I'm curious how many of those prescriptions really are.

This is a sensible thought. But people without insurance are charged more because they can be, not because they are willing to pay. Insurance companies have fee schedules, and I would bet you the amount of the prescription that the pharmacy has a different rate for people who are not insured. Insurance companies are not going to pay $418 for topical fungal treatments; they pay what their schedule says and the pharmacy has to accept it if they want their business.
Mind you, this type of predatory pricing seems to be a US phenomenon. I haven't run into it in Canada (I have primary care coverage same as everyone, but i don't have extended benefits so pharmaceuticals aren't covered) and I know in Japan drugs are sold at the same price whether you have extra benefits or not (I believe they have laws around pricing).

MrsWolfeRN

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #20 on: February 14, 2019, 05:12:45 PM »
I thought of this thread when I read the attached article. In many developed countries were there is no single payer system, the government steps in and controls prices so healthcare is much more affordable than in the US.

https://www.truthdig.com/articles/this-may-be-the-only-viable-alternative-to-medicare-for-all/

Abe

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #21 on: February 14, 2019, 08:14:17 PM »
Please refer to the universal healthcare thread for a detailed discussion of drug pricing, but for everyone's benefit here:

In the 1990s to early 2000s there was a lot of direct-to-consumer marketing that convinced physicians and patients alike that some drugs in a given class were better than others. For the most part, and for complicated reasons, that dynamic doesn't exist anymore. It is now a chess game between insurance companies and drug companies about how each maximizes their profits and minimizes their costs. Perceived medical benefits of the drugs within a class have little to no role in these decisions anymore. This is because the US is the only developed country without some type of price control on prescription drugs.

MissNancyPryor

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #22 on: February 14, 2019, 08:28:45 PM »
Speaking of fungus....

Many moons ago, when I was preggers I was prone to yeast infections, something about the hormones.  The stuff to fix it for the ladies was like $26. 

Same exact stuff in the same concentration is $6 when you buy it for athlete's foot.  No issue about applying it to, er, ahem.... delicate areas.  Worked great.  Same stuff is slightly more expensive when packaged for jock itch but still way less than the ladies' aisle.

Yep, lots of screwed up pricing out there.   

 

DadJokes

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #23 on: Today at 08:54:15 AM »
Speaking of fungus....

Many moons ago, when I was preggers I was prone to yeast infections, something about the hormones.  The stuff to fix it for the ladies was like $26. 

Same exact stuff in the same concentration is $6 when you buy it for athlete's foot.  No issue about applying it to, er, ahem.... delicate areas.  Worked great.  Same stuff is slightly more expensive when packaged for jock itch but still way less than the ladies' aisle.

Yep, lots of screwed up pricing out there.   

I read an article (maybe posted in these forums) about how people are gaming airlines by buying tickets for a multi-leg trip and then getting off after one leg because it's cheaper than buying a direct flight to that location.

For example, the guy wants to go to Denver, so he buys a ticket to San Francisco that stops for layover in Denver because it's cheaper. The airlines are charging based on demand, not cost + markup.

If I had to guess, I would guess that most industries, including pharmaceutical, do the same thing. It's pretty crappy on their part, but it's nice when there are ways to game the system.

MissNancyPryor

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Re: 98% Savings (Unbreaking the Broken Medical System)
« Reply #24 on: Today at 10:24:09 AM »
Funny you mention that-  in the last 48 hours I read that Lufthansa started suing people who do that well-known travel hack. 

https://finance.yahoo.com/news/lufthansa-suing-passenger-skipped-flight-185845008.html