Sunday, September 16, 2007

Dear ABC, 20/20, and John Stossel... please...PLEASE!!!... "Give ME a Break!"

Friday night ABC aired a special 20/20 news report "American Health Care in Critical Condition" presented by John Stossel and Andrew Sullivan. However, an earlier preview of the show was billed as "Healthy in Cuba, Sick in America?" Even last Wednesday, Stossel published "Cuba has Better Health Care than U.S.?" So you would think that the show would focus on the 'universal' healthcare debate and proposals of presidential candidates, but it didn't. The change in focus did not go unnoticed as reported Trisha Torrey at Every Patients' Advocate, "Stossel, 20/20, Bait & Switch, Naivete."

In my opinion, Stossel's report was propaganda in favor of the health insurance industry proposing 'market-based' solutions. Stossel uses information provided by Karen Ignagni, president and CEO of America's Health Insurance Plans (AHIP), who represents the interests of the health insurance industry. Of course, representatives of the health insurance industry would be opposed to any solution which takes power away from for-profit companies. In fact, recently, Ms. Ignagni has been lobbying furiously against portions of the SCHIP bill which diminish government subsidies for insurance companies offering Medicare Advantage plans. In June 2006, the Commonwealth Fund issued a report, "Medicare Part D: A Successful Public-Private Partnership" by Ignagni.

Back to the crisis of healthcare. If you've seen or heard anything about Michael Moore's film "SiCKO" you know that he, his film crew, and eight American patients travel to Cuba and receive medical attention at a Cuban hospital. Some viewers may say to themselves that Moore staged this 'stunt' in Cuba just for the controversial publicity it stirred up for the film and the oodles of money Moore might garnish from the proceeds.

If so, you might begin to wonder about those 'patients'...

  • Come on now...were they real people, or actors?
  • Couldn't they just see a doctor or go to Wal-Mart for $4 meds?
  • Hey, just go to the ER....that's where the poor and uninsured go.

Solution...get insurance...see doctor...take problem. See?

But wait a minute...

Didn't Stossel claim that too many Americans irresponsibly use their insurance coverage and thus are to blame for the escalating costs of health care in America which indirectly causes the tens of millions of those without insurance to be unable to afford coverage?

He did indicate that too many patients are unaware, or don't care, what the actual costs are for the care they seek. He assumes this is because the majority of insured Americans receive their health benefits through employer-sponsored, group package deals struck with the insurance company. Often (though at a declining rate recently), the employer pays a portion of the premiums as doing so is a tax write-off for the employer.

I do agree with a portion of his theory. Who does know the exact cost to see the doctor or the real price of a prescription refill? In health care, the concept of 'suggested retail price' doesn't exist. And even in retail, the 'suggested retail price' doesn't represent the actual cost for obtaining the item or service. That number doesn't really mean much, now does it?

Who sets the price....the doctor....the pharmacy....the drug company....the hospital....the lab....the manufacturer....the insurance company....the benefits manager....the government....the customer....the patient? I think we can agree that the patient is the one with the least amount of power over the rising cost of health care services. It's not like shopping at the grocery store and choosing the brand of spaghetti sauce which happens to be on sale that week to save a little money in the family budget.

When the insurance companies are involved, relevant questions become--
  • What is the allowed or negotiated rate?
  • Is this service excluded from my coverage?
  • When does insurance stop paying for my care?

When one has health insurance, he expects that the insurance company has negotiated fair allowable rates with those health providers 'in network.' Personally, I like the 'in network' concept... as long as my preferred doctors, the local hospital, and convenient pharmacies are 'in network.' Each time I receive a Explanation of Benefits statement from my insurance company, I note the rate billed by the doctor (or other provider), the rate which was 'non-allowed' by the insurance company, the amount which insurance paid, and the amount for which I am responsible. If I owe more than the copay rendered at the time of service, I know a bill will be arriving soon.

Example of charges/payments for doctor's visits I had this year:

  • $78 billed - $22.04 non-allowed - $25 copay = $30.96 ins.paid
  • $142 billed - $54.49 non-allowed - $25 copay = $62.51 ins.paid
  • $164 billed - $76.49 non-allowed - $25 copay = $62.51 ins.paid

Example of lab charges/payments also this year:

  • $120.42 billed - $102.17 non-allowed - $1.82 co-ins. = $16.43 ins.paid
  • $135.30 billed - $115.30 non-allowed - $2.00 co-ins. = $18.00 ins.paid
  • $181.10 billed - $156.65 non-allowed - $2.44 co-ins. = $22.01 ins.paid

Although I may not know the true costs involved in seeing the doctor, I do know the dollar amounts which have exchanged hands as a result of my having seen the doctor. Just I do not know the true costs involved in getting that on-sale jar of spaghetti sauce to the local grocer's shelf, but I do know how much I paid for it. Mr. Stossel please do not insult us in claiming that consumers of health care do not know that there are costs involved in receiving that care, regardless of how the dollars are exchanged between the interested parties.

Stossel's recommendation of Health Savings Accounts (HSA) as a means to fix the problems with our country's health care crisis reveals his libertarian preference for market-based solutions and limited government regulation. A prime feature of 'consumer-driven' health insurance products is the HSA which is typically paired with a high-deductible plan. The theory behind the HSA is that patients will more carefully choose how their healthcare dollars are spent when they are taken out of a personal tax-preferred account which, if left alone, could continue to grow through retirement. And by being more aware of each dollar spent, consumer-patients will research and negotiate lower prices, ultimately leading to more competition for healthcare dollars and thus lower healthcare costs.


Let me share a story. My individual private health insurance policy covers prescriptions... but with an annual cap of $1500. To receive the negotiated rates, I must fill prescriptions at an 'in network' pharmacy and use generics if available. To save on maintenance medications, I use the preferred mail-order pharmacy, Walgreens, which is the only mail-order pharmacy which must honor my insurance's negotiated rates. My insurance company employs an outside pharmacy benefit manager, Argus Health, to negotiate and manage pharmacy benefits. However, Argus does not require that Walgreens obtain stock from the least expensive manufacturer or wholesaler. In the case Gabapentin, a generic version of Neurontin which is manufactured by several generic drug companies, there are nine different NDC (National Drug Code) codes and prices, but only one which Walgreens stocks.

Knowing in June that I was approaching the $1500 limit, I called Argus to inquire as to what the negotiated rates were for each of my medications. I simply wanted to be able to budget appropriate for the increased cost as I had already spent $500 year-to-date and was looking at spending another $2000 minimum to the end of the year. A very patient woman worked with me in determining the negotiated rates for ten different medications, both in brand and generic forms. When I attempted to refill the gabapentin prescription through Walgreens, I was unpleasantly shocked to find that the 'negotiated rate' was twice what Argus customer service had quoted. After several phone calls, to Walgreens, Argus, Walgreens, Argus, Walgreens, and Argus again, it was revealed that of the nine sources of gabapentin, Walgreens only stocked one choice and that not being the least expensive.

I was not happy and wanted to know the exact amounts my insurance had paid toward each prescription filled and I politely asked for this detailed information. It was becoming clear just how my insurance company had 'blown through' my $1500 pharmacy benefit so quickly.

The report states:

  • Total scripts: 9
  • Total price: $307.02
  • Using generics saved you: $0.00
  • Your insurance saved you: $3510.79

*All nine prescription fills were for generics with $307 for
copays. This does not include prescriptions filled at the local
Rite-Aid. But what EXACTLY did my insurance PAY!!!! You better believe it wasn't $3500 when they stop paying at $1500.

I don't appreciate that my insurance company paid too much for my meds, leaving me with higher expenses beyond the $1500. In the 7 years I have had the same policy, the annual limit for medications has never increased while the premiums have increased 88%. Carefirst is able to offer such a policy because it is an individual policy. Individual policies are not subject to the same regulations as group policies. In Virginia, this leaves individuals, like me, not covered for a basic need such as maintenance medication. This results in patients going without needed treatments, drug companies having little incentive to keep prices lower, insurance companies being allowed to sell insufficient (essentially unregulated) policies to persons without employer-sponsored benefits, and ultimately much waste in the financing and spending of healthcare dollars.

Trying to come up with a solution to the fighting over access to those healthcare dollars reminds me of lunchtime in elementary school. I grew up in a poor section of Oklahoma City and attended an elementary school which had a government-subsidized lunch program. Of course at the time, I had no idea that what was available to me on a daily basis was anything out of the ordinary. For many children, lunch was likely the first meal of the day and maybe the best meal. Every child received a well-balanced meal and if you were still hungry, you were allowed to have seconds. Knowing that you would not go hungry eliminated the urge to hoard food or any need to fight over access to the biggest portions. No negotiations over lower prices, no stealing or cheating, no begging for charity care, no being sent away for inability to knew you would be fed and learned not to be wasteful.

I hope for a day in which receiving HEALTH CARE and MEDICAL CARE will be as dependable as that daily school lunch 30+ years ago. So far the best solution I have studied is found in the idea of Medicare for All. For a nice description of how this would work, read "Single Payer- Grassroots & Tactics" by DrSteveB at the Daily Kos.


"Single-Payer Health Coverage: Scary Boogey Man or Super Process-Improvement Force in Health Care Reform?"

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