This is why healthcare costs are so ridiculous

[slsh]

Utterly insane. It aggravates the heck out me when I am dealing with a total lack of basic common sense.

Boo has to get feeding tube supplies monthly. Has for years. The most pricey part of it is the bags - like IV bags. Have to use 1 per day (impossible to clean out formula from many feet of tubing). So our ins co has been adopting the reject reject reject strategy lately (unusual for them). Latest bologna excuse is that Boo's maxed out medication/surg supply benefit for the year - there is no max on medication/surg supplies. So whatever, called them and asked them to reprocess the claim for the fourth time.

But here's where the real insanity comes in. We have a PPO, and there's not a chance in Hades I'm ordering from their participating provider again until this last claim gets paid. The participating provider charges... sit down for this... $1690 per *month* for these bags. The negotiated fee is $195, so the provider writes off the difference and our ins co pays 80% of the $195 until we meet our stop loss, which we do every year with- him, and then they pay 100% of it.

So I pop on to good old Amazon and find the identical bags for, catch this, $150. Yep, less than 10% of what the preferred provider would charge me if I had no insurance and $40 less than the negotiated rate our insurance co pays. by the way, bags have arrived and actually are identical, plus they got here in 2 days.

So, because I try to be economical, I ask ins co if they will pay the significantly lower rate for these bags at preferred provider rates. They say no, they will only pay as a nonparticipating provider (which means a $900 deductible first and then they would pay only 60%). So I call husband's employer (huge international corporation that is self insured, ins co just administers). Could not have been more unhelpful, punted me back to ins co. So I call ins co again.... well, you can imagine how that went. I finally in frustration put it in the bluntest of terms.... Ins co would much rather pay more $$$ to someone they have a "contract" with- than pay a cheaper provider who they don't have a contract with without burying us in a hole of medical debt because we would have to pick up the nonparticipating deductible/copay/stop loss. They would save $ not only by paying less for the actual service, but also because that would mean we would hit our stop loss later in the year meaning they'd have to pay less claims at 100%. They would save roughly $400/yr. Granted, that's probably nothing to them, but still, a savings is a savings.

So I told this ridiculous woman who couldn't stop harping on and on about contracts that fine, we'd just keep on ordering the more expensive supplies and they could just keep paying more than they have to.

It's just ridiculous. Honestly, they ought to let people who actually have to make ends meet administer these plans.

Stepping down now, LOL.

 

[klmno]

Just shaking my head....unfortunately I'm not surprised. I really think there is a significant lack of common sense in our society anymore.

 

[Mamaof5]

It always breaks my heart to see my American friends go through this kind of **** with ins co's. I can't fathom the heartache, frustrations and pain that this causes. My sister in law has disabled twins, one uses a mickey for feeding (stomach tube, same as your little one). She gets her supplies every year and they pay (OHIP - ontario health insurance plan and the ODSP - severe disabilities pension) for everything without co-pays, without any real problems at all. Does the USA have a severe disability pension plan in place for its citizens? It's amazing how much the Canadian gov gives out for disabled people - ODSP, ACSD (children with severe disabilities funding) CDB (childrens disability benefit on our child tax benefits).

Mind you, we can pay extra for personal private insurance on top of our provincial health plans (and we do pay for the OHIP in Ontario off of our paychecks now - 5 yrs running - called the OHIP tax) but most don't need it. If it weren't for OHIP my 2 c-sections would have bankrupted me 7 ways to Sunday big time.

I feel so horrible and angry for Americans who end up with big big bills for medical needs. It's just not right. Now that the US gov is pushing through this INS thing with legislation (which is NOT uni health care quite frankly, its INS forced on people) I wonder just much more in dire straights Americans will be. I hear Mexico has an even better Universal Health Care system than Canada or the UK does??? Interesting concept that is.

Uni health care isn't a good model but its better than most. I hope the ins co smartens up (wishful thinking or hoping I bet) soon. Really, you try to save them money and they complain about contracts? Maybe you should go work for them as a consult and teach them about saving money concepts???

 

[SRL]

This happened to a friend of mine while she was on home health care. She needed syringes filled with saline to clear a picc line. Syringes are cheap and a bag of saline is cheap. Cost for the filled syringes (which they did there at the pharmacy) was exhorbitant, and were passed on to her through her copay. She asked if she could fill them at home (maybe about 30 minutes of her time), but they couldn't do that due to the contractual agreement.

Ridiculous!

Mamaof5 I agree that it's heartbreaking but I just read an article that said Canada's system is headed for serious financial trouble, with Ontario saying healthcare costs would be 70% of its budget if it continues in the current state.

 

[Shari]

I hear ya and I feel for you.

I take BCP continuously for endo. When I went to pick up the first pack this year, the pharmacy asked for $55. It had always been $10 before, because I use generic.

The generic had given itself a name, so it now fell into a new class with my insurance company. "Branded generics" with a $55 copay. The cost of the medication to the pharmacy was $9.95. The outright cost the pharmacy would charge me was $14.85. IF I used my insurance, I had to pay $55.

And come to find out, the ins company has a contract with the name brand now. So the name brand has the $10 copay. The name brand costs the pharmacy $70. Out of pocket to me for the name brand would be $90. What sense can that possibly make...the ins company paying $80 instead of $4.

I buy the generic outright for $14.85 and don't run it thru ins just on the principle - whatever kick the ins company is getting from that big pharmaceutical company, well, they aren't getting it from me. At the end of the year, I'm going to file all the receipts for my generics and see what they do with it.

The system is very, very broken.

 

[Mamaof5]

This happened to a friend of mine while she was on home health care. She needed syringes filled with saline to clear a picc line. Syringes are cheap and a bag of saline is cheap. Cost for the filled syringes (which they did there at the pharmacy) was exhorbitant, and were passed on to her through her copay. She asked if she could fill them at home (maybe about 30 minutes of her time), but they couldn't do that due to the contractual agreement.

Ridiculous!

Mamaof5 I agree that it's heartbreaking but I just read an article that said Canada's system is headed for serious financial trouble, with Ontario saying healthcare costs would be 70% of its budget if it continues in the current state.

I am very aware of that particular problem - who created it McGuinty with squandering the last 5 yrs of OHIP taxes on ehealth in the billions. They scrapped the ehealth thing after a big scandal and fiasco about it last summer. Freaking government...they create the budget problems (and I swear it's for job security for these devil politicians). Now they are thinking of splitting the health care into two tier health care - public and private - those who can afford private will rely heavily on the private sector opening up and those who cannot afford (like me) will have to rely on a very skinny and reduced public health care system. They already dropped eye doctors off of OHIP for under the age of 16 (meaning we pay for it if 16 and over now, under 16, every two years the OHIP pays the fees of the eye doctor).

Canadian Gov touts no one left behind while they silently kill half the uni health care with scandals and budget cuts then hit us with HST (harmonized sales taxes starting in July)...It's a wonder we can even recover from economic slow down...McGuinty has been a black stain on the province for some time now.

 

[Marcie Mac]

Three months of my BiPolar (BP) pills is 60.00 if I use my insurance - Get the same stuff at Walmart for 12.00. Plus they will give me the whole 3 months rx at one time - at SavOn, I have to go back every month to get one packet, not to mention I have to make a phone call before I go pick them up cause I gotta call each one in. They will NOT let me just pay for them without using my Prescription card, because, you know, its on file (and they are 6.00 each if I COULD pay cash there)

Every time I hear someone say our Health Care system is just fine, I wanna smack them.

Marcie

 

[Shari]

Three months of my BiPolar (BP) pills is 60.00 if I use my insurance - Get the same stuff at Walmart for 12.00. Plus they will give me the whole 3 months rx at one time - at SavOn, I have to go back every month to get one packet, not to mention I have to make a phone call before I go pick them up cause I gotta call each one in. They will NOT let me just pay for them without using my Prescription card, because, you know, its on file (and they are 6.00 each if I COULD pay cash there)

Every time I hear someone say our Health Care system is just fine, I wanna smack them.

Marcie

Your situation is just like mine. I want to know how the ins company jacking up the price is even legal.

 

[CrazyinVA]

Oldest used feeding tubes for about a year at age 12 because of her Crohn's. Luckily, my insurance covered the tubing/bags/pump 100%. They would not, however, cover the nutritional liquid that went into the pump, which at the time was about $10 a can (she used 4 cans a night, 7 nights a week). They told me the reason was that if she did not need the tube 24/7 (she did her feedings overnight), it was considered a "nutritional supplement" and was not covered by my plan. Never mind that being on the feeding tube at night kept her out of the hospital for all that time, saving them thousands upon thousands of dollars. Fortunately, my self-insured employer at the time was a healthcare supply distributor, and we actually carried that product in our warehouses. So, they basically shipped it to me and wrote off the cost. Talk about lucky.

We also ran into issues with another Crohn's medication ... the "recommended dosage" for a 30 day supply , according to the insurance company, was less than what her dr. prescribed, therefore they wouldn't cover the difference (i.e., she was taking 3 pills 3 times a day, they said they would only cover 2 pills 3 times a day). I ended up fixing that by getting samples from the doctor, but we cut it close a couple of months.

Then there was the icing in the cake, the insurance company having no pediatric psychiatrists on their list of providers, and telling me, no joke, that Oldest "didn't really need a child psychiatrist," an adult psychiatrist could treat her just as well. I raised enough of a stink over THAT, that they let me go out of network.

These situations were all a long time ago, but I don't think the system has changed much (other than perhaps the child psychiatrist angle). I don't get how non-medical people make medical (and psychiatric) decisions at insurance companies. It baffles me.

 

[Nancy]

That is insane Sue. We ran into the same thing when my mom was on a ventilator. We could buy most of her feeding and breathing supplies ourselves for so much less than the medical supply companies were billing insurance. Mom was just about to run out of her $1 million cap when she passed away. As it was I finally negotiated with the insurnace company to let me hire our own nurses (which were required because of the ventilator) and pay them out of my pocket and they reimbursed me. We were able to stretch three more years of coverage this way. Instead of paying a nursing agency more than twice what the nurses made, we paid them directly, got better nurses, and mom stayed in her home until the end.

Here's another one.....easy child had to go to the hospital last month due to an ovarian cyst. We got the hospital bill for $9,400 not including doctor visits and ultrasounds and cat scans. The contracted price was $1,700. Since we have a deductible of $10,000 per person we had to pay the entire $1,700. But why the huge difference in price? She was in the ER for 16 hours.

Nancy

 

[muttmeister]

Every time I hear someone say our Health Care system is just fine, I wanna smack them.

Amen, amen, amen. What planet do these people live on? Every time I hear that the devil in me makes me think I wish somebody in their family would get sick and then they'd see what the rest of us have to deal with. Of course, I don't REALLY want that, but maybe they'd actually learn something.

 

[slsh]

Crazy - you'll appreciate this. When we first started out with- the tube feeds (20 years ago), I tried to get ins to pay for the formula. Their response was just priceless.... "No we won't pay for formula because you can put table food in a blender and liquify it." I just about fell over - we were talking at the time about a preemie who hadn't even begun to catch up on the growth charts and who's nutrition was (obviously, duh) a huge issue due to his CP. It's been fun and games ever since. Never have gotten anyone to reimburse for the formula.

Nancy, I also worry about that lifetime cap. Fortunately husband changed companies about 5 years ago, so we got to restart the clock, but I figure Boo probably runs about $55,000 a year when he's *healthy* (throw in a couple of seizures and you can double/triple that, easy). He may well be maxed out by the time husband's company stops covering him anyway... then we will be on to Medicaid, which I'm dreading. And I *so* hear you about those real costs versus reimbursed rates. It's all funny money and shady accounting in my humble opinion. What ends up happening is the uninsured, who can least afford it, get clobbered to make up for the "negotiated rates" our insurance companies get.

I did discover today that we actually have unlimited inpatient mental health days now (thank you, parity), LOL. Murphy's Law of course. thank you is no longer on our insurance.

It just all seems so completely backwards and runs counter to cost containment. I'm in the process of writing a letter to husband's company explaining that this is a pretty stupid way to run things, especially since they've implemented some real PITA policies (health coach for husband this year, and I have to get one next year) to cut healthcare costs.

 

[CrazyinVA]

Ha! That does NOT surprise me somehow, slsh. When I changed employers and insurance companies after our debacle, and Oldest had to temporarily go back on the tube feeds, that insurance company paid for the formula 100%, I was shocked (I had been ready for another battle!).

I've actually been surprised at how well Medicaid has worked for Youngest and her son, she's had almost no issues with them, everything is covered 100%, no out of pocket at all. She's yet to find a provider that doesn't accept Medicaid, too. I know that's not always the case, though.

 

[klmno]

She's yet to find a provider that doesn't accept Medicaid, too.

That completely shocks me! I had been led to believe that finding providers was a major issue around here. And I saw signs in both dr's offices and psychiatrist/tdocs offices saying they did not take medicaid patients any longer. Not to hi-jack the thread, but if it turns out that difficult child comes home and we are still in this area, I might PM you to find out which providers are accepting this because difficult child will have to go on medicaid.

 

[AnnieO]

Interestingly enough - my insurance refused to pay for several things... The prenatal vitamins I was on, they paid the first month, my copay on those was $9. Next month, they said I didn't have insurance. I paid the full amount - $16. Third month, same thing - and then. And then.

All these interesting things? Progesterone suppositories (UGH), my insurance "saved" me $306 - I paid $29.95 - and on the Xanax (3 0.5 mg tablets) - they paid $7, I paid $1.25. Huh? The birth control? With insurance, copay is $25. Without? Costs me $11. WAIT. Huh?

There are more. Strangely though, I still cannot use the insurance because the ID# doesn't work. So I ordered new cards. Didn't get, didn't get, didn't get, called and went up like 4 levels. They better be in my mail by Friday. because guess what? My ID# changed due to - UH OH - premium change. But they never notified me. I get a premium change every year. Never have I needed a new ID#. Not even when I got married.

 

[muttmeister]

I keep hearing how "awful" a government controlled plan would be and how "awful" Medicaid is but I don't see it. Younger difficult child and his family are on Medicaid. They have had no trouble finding doctors and no trouble being treated. After their car accident at the end of March daughter in law's bill was over $70,000 with surgeons, hospitals, physical therapy, etc. We ended up paying about $40. She got wonderful care and is recovering nicely. The upshot is, they can get treated whenever they need it. I have needed a doctor for several years for a couple of issues but I will not be able to see one for 2 1/2 more years when my Medicare kicks in because I cannot afford to go now. I do not begrudge the people who get Medicaid. It just makes me mad that the rest of us can't get medical care because we are not millionaires.

 

[GoingNorth]

I have Medicare as my primary and ChampVA (VA) as my secondary. Not only do they mesh very nicely together, but my VA "part D" allows me to get my medications for FREE if ordered through their mail-order pharmacy.

I live in a small town of 8K people and have no problems finding a local provider

 

[susiestar]

The reason insurance companies pay more to get the same medications is because the people at the top get HUGE kickbacks from the pharmaceutical companies. It is not called a kickback, because those are illegal, but it is the same thing. MANY insurance companies are major, but hidden, shareholders in pharmaceutical companies, or the top execs/shareholders at the ins co are top execs or shareholders at the pharmaceutical companies. It is largely hidden under different company names, etc.... but when traced back it has been found to all be the same in many cases.

NONE of the ins cos and pharm cos are running things with the good of anything but the almighty dollar in mind. With many drugs, the profit from one year of their protected sale under the brand name, when no generics are permitted, can pay off the cost of research and development for that drug. Then they have many years of pure profit before they are eligible to become generic. There are some drugs that have taken more than 1 year to pay the costs, but I doubt any of them took the full amount of time they are protected. Once the timeline for brand name protection is about to run out the company can extend that pure profit timeline by finding an alternate use for the medication. If they can prove that a blood pressure medication can prevent migraines, for example, they get more years before it is available in generic. This happens even though the migraines are prevented because the medication lowers blood pressure, NOT because it does something else in the body. It is an economic disaster for those who need that specific medicine - many cannot pay for it.

husband was put on lexapro for some problems quite a few years ago. From the beginning I kept urging him to ask the doctor if there was a generic that was roughly the same. Of course there was. Lexapro came out because the older drug started being available in generic. The makers changed it a tiny bit saying it has radically fewer side effects and is more effective and sold it as lexapro. FINALLY, about two months ago I went with him to the doctor for his skin cancer removal and I asked the doctor to switch him. husband was truly shocked that we are saving about $40 a month by not using the insurance we pay through the nose for and by going to walmart to get the medication. He has since gone through ALL of his medications with the doctor to make sure he is on the cheapest version of all of them. He was esp surprised that the older medication seems to have fewer side effects than the lexapro.

I cannot wait until the kids are switched over to medicare. Or whatever the state kids insurance is. We have had a hard time getting it processed, having sent the forms in several times already. Finally we did them at the office in front of a worker. Should hear something this week. It will mean we have NO copays. The docs seem to like it because there are few limits on the medications they can rx, unlike private insurance with their formularies. Many medications contract with medicare because they can reach a huge market that otherwise they couldn't access. We figure we will save about $200-$300 per MONTH in copays for visits and medications because each kid has some medical issues. Heck, we will automatically get a new nebulizer for T because he is under age 16 and has asthma. They used to send one every year, now it is every 2 years. In the past I have tried to send them back because the old one still worked and they wouldn't take them. So I have passed at least three of them, with tubing, on to friends who have private insurance. It seems stupid to have more than one of them in the house. At least it does to me. He will get the neb and the medications in addition to the inhaler he uses. I do NOT understand it and often do not fill the neb medications more than once. It is handy to have them on hand for when he gets colds because it does work better than the inhaler. But it is not as convenient to use.

The specialist that Jess will see in Texas even takes our state's medicare. I was happily surprised. They told me they have less hassle getting paid by medicare than getting paid by our private insurance, and that medicare covers more!! I was shocked.

I think that the entire insurance industry/healthcare industry needs to be revamped into a system that is less profit based. Not sure how to do that though.

When I run the world it will be different. LOL.

 

[Shari]

Good deal, Susie. Looking forward to it, cause the way it is now is ludicrous.

 

[KTMom91]

In our county, we no longer have an emergency mental health crisis dept. Services are being cut right and left, and I've seen the sign that doctors no longer accept Medi-Cal at several different places. We're still paying COBRA, which is more than our house payment, and are trying to hold on till August, when Miss KT comes off the insurance, to see what our options are. I have a sneaking suspicion that our options will be slim to none, leaving us no choice but to go to the ER and let the county eat the costs, since we aren't eligible for Medi-Cal. We have two 10 year old cars, and a 35 year old pickup truck, and those vehicles push us over their limits. The fact that Hubby's on unemployment, and I only work part-time, have nothing to do with it.

Anyway...