Hi Costs, Hi Insurance, Hi Anxiety, Bye Money

Just now, I noticed all the media attention on the Idaho Medicaid hearing going on. It’s not just Medicaid, but Medicare, health insurance, medical costs, pharmaceutical prices, the recession, so much that just adds to my stress level in a very unhealthy way.

When I first started dialysis, I had the blessing of a staff at the center who manages all my financial worries. It’s a huge relief. Dialysis costs around $250,000 a year per patient. It’s a booming business. But how much of that is actually the cost of running dialysis? That $250,000 is what insurance companies, and also Medicare as secondary insurance, pay – so what was it originally? I ask this because three weeks into dialysis, I went to Orlando and vacationed near a different dialysis center and later was billed for $8,000 for the week. (My center is $12,000 a week.) When Premera wouldn’t pay (because it was “out of network”), the Orlando center sent me a new bill, written down to $800. That is 90% of the total bill. Then, after I paid $100, they zeroed out the balance. So, dialysis for the week cost me $100.

Another little tidbit: A transplant costs around $500,000. Medicare will cover a dialysis patient for the rest of their life on dialysis at $250,000 a year. Medicare will cover the prescriptions (usually around $3,000 a month) for three years post-transplant, around $100,000, and then NOTHING. So, think about this for a second. I can be on dialysis for 30 more years ($7,500,000 – that’s seven MILLION, five hundred thousand). Or I can have a transplant with the initial cost of $250,000 to $500,000, plus three years of medication (which is required to keep my new kidney from rejecting, and that I need to keep taking for the rest of my life, not just for three more years).

My family has a genetic kidney disease that causes End Stage Renal Disease which is fatal if not for dialysis or a transplant. Two of my siblings have had transplants. My sister was doing well until the three-year period had passed, when she became solely responsible for her medication costs. She lost her job because she was out sick too many times (the result of other people’s “common cold” where she would end up in the hospital to save her kidney). (Fact: most people on dialysis lose their jobs because of all the time they are unable to be at their desks). She felt the only recourse was to sell her house, become indigent, and eventually become eligible for Medicaid because Medicare quit after three years post-transplant.

My brother had a transplant five years ago this April. The following is part of an email he just sent to me. I am fearful that the pending health care reform will further hurt the thousands upon thousands of people dependent on drugs or treatments to keep them alive. Will we all become expendable and our expiration tags pulled?


Last Monday I called Group Health Pharmacy to verify that they would not bill a 3rd party drug provider, which they will not. Then I insured that they would be able to fulfill my prescription of cinacalcet at 90MG, once a day and that I would be able to pick up a 90 day supply, verifying that I would indeed need to pay $1954.50 up front. Tuesday I showed up at the pharmacy and the young lady at the counter showed up with the bottle, rolled her eyes and said, "Yikes!". This was the same reaction I got from the pharmacy clerk at Costco, where I had gone to pick up this prescription on the previous Saturday. As an aside CostCo couldn't sell it to me because when they ran my Group Health card the latter refused the payment stating that I had to go to the Group Health Pharmacy for this purchase (those assholes [Group Health] are really on my shit list, btw). Then the afore mentioned young lady said, "Do you know how much this is going to cost?" I dead panned her with my now stock answer, "It's that or die." There is no real come back for that. Then the young lady told me it would be $651.50 - to which postal, nuclear bombs went off inside me (that is a 30 day, not 90 day supply).

Now I know it wasn't her fault, however the previous day I had spent almost 1 1/2 hours on the phone with three different people from Group Health verifying that the prescription would be correct and waiting when I showed up. Really. How does Joe Paying Customer get a mega buck giga corp to listen to him? It wouldn't be that huge, but I have already been shunted down to their pharmacy rather than a pharmacy of my choice, and once I get home I call my 3rd party to tell them I have the drug in hand and would they please send a reimbursement form, which takes 7 to 10 days to arrive, which I then have to fill out, affixing the original receipt plus the sticky prescription label from the bottle, then mail and wait an additional 4 to 6 weeks for reimbursement. Now, because they only coughed up 30 days I have to do this all again on April 1.

Anyway, bottom line, the drug costs $1303.00 per 30 day supply. Group Health will pay 1/2 leaving $651.50. The 3rd party (which happens to be the drug manufacturer) will then pay $500.00 leaving me with the remaining $151.50 per month for this single medication. That is on top of an addition $66.66 for the rest of my medications for a total of $218.16 per month. It could be worse, but, damn - that is coming close to a car payment, and the Wife really needs a new car.

However, the reimbursement form arrived in yesterday's mail which made it only 7 days and I have filled it out affixing all required labels. So, now that Susan Delfino (of Desperate Housewives) is going to be getting her transplant (oh, poor thing) I wonder if the writers will bother following up on how that only solves this handful of problems, but creates a whole new set to deal with.


Al said...

As a follow up: the reimbursement will actually take about 8 weeks. Since my share is $151.50 of the original $651.50 that basically puts $500.00 out of reach for two months. On top of that I do this again for a 90 day supply on April 1. That then puts an additional $1500.00 out of circulation for other things, oh say, mortgage, food, heating, fuel...

Don't get me wrong, I really, really appreciate the fact that Group Health will pay the 50% and that the drug manufacturer is contributing $500/mo (keeping in mind that the manufacturer is contributing because they know if they didn't they wouldn't get any of that money because the cost is a quick ticket to bankruptcy).

So, what is the answer? Obama's Health Care Reform? The Republican plan? The Tea Party plan? I would hazard to guess no one knows. And I mean no one; not Obama, not the politicians ... no one.

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