Humira in one month supply only.

http://www.edmontonsun.com/news/columnists/kerry_diotte/2009/08/13/10445326-sun.html

I wonder why bureaucrats can be so inflexible?

A regular reader wrote to say he's being treated for Crohn's disease and the Edmonton-to-Arizona snowbird can only get a month-long supply of a vital drug from Blue Cross, called Humira, that could put his disease into remission.

"My choices would be to fly back from Arizona to Edmonton every month this winter or go to an American specialist to have him prescribe the drug," said Alex Harboway.

Either way could be very costly. After months of dealing with Blue Cross and Alberta Health, Harboway has caught a bit of a break. His other insurance company, Sun Life, will pay 80% of the cost of the drug for a 100-day supply. The cost of the drug here is about $1,700 a month. He'll pay the rest out of pocket.

"I've never jumped through hoops like this in my life," he said. There's no question it's a valuable drug. Indeed, Harboway has been told it's similar to the one that has helped Oiler Fernado Pisani to recover from ulcerative colitis, a very serious disease related to Crohn's.

First of all, dood's got three insurance companies that will cover this one way or another!

The American specialist would cost this financially impoverished snowbird that flies back and forth between Canada and the US $350. With the deal that he's worked out he's already paying just about that much on his monthly deductible for the drug. A plane ticket to Canada is going to cost about that much as well.

One reason an insurance company might not want you walking away with a one year supply of $20,000 worth of drugs is that you very well might have to discontinue the drug before your one year supply is up. This happens all the time with Humira---there are all sorts of reason why this might happen. And once you've bought it, you'll have $20 grand of expensive protein sitting in your fridge right next to the leftover potato salad.

Recently a woman offered to sell me a one month supply of Humira (she had discontinued it) for a few hundred dollars cheaper than what it retails for. She would have pocketed this money, of course, at the expense of her insurance company who paid for the drug. I didn't take her up on her offer since whatever I pay her doesn't count towards my out of pocket max, and secondly, I don't trust anyone but me to keep this drug properly refrigerated.

Imagine Insurance CEOs did get those million dollar compensation packages....

H. Edward Hanway, chair/CEO, Cigna Corp., $30.16 million compensation: 11 million insured. If he worked for free then each insured would pay $3 per year less in premiums on a policy that costs about $10,000 or more per year.

If their $1.7 billion operating expenses were reimbursed to the insured, they'd save less than $200 per year.

Savings we can believe in!

Providers make more mistakes than my insurance co.

One of the things that I worried about when I got sick was that my insurance company was going to rip me off somehow.

Year To Date:

1. I have been balance billed by a provider which I unwittingly paid and never received a refund, billing service will not return calls so that I can get refunded.

2. Been misreported as delinquent by a provider to a credit collections agency which billing service agreed was a mistake after I suffered through a month of nasty collections calls. "We changed billing services and this is happening to a lot of our patients. Soooooorry" I changed docs immediately with that.

3. A dentist told me my insurance company would pay for some dental work which was necessary. You can guess the rest and skip to #4 or keep reading.

He got the work half way done, refused to do more work until I paid the insurance company's portion telling me the insurance company had denied the claim three weeks ago and wasn't going to do any more work until I paid the ins co. portion. So I paid. Turns our the insurance co. never denied or paid the claim because dentist never did file the x-ray. Claim was just sitting in insurance limbo. Even after I stood there and insisted they do so he wouldn't file that xray (he's PPO not indemnity) so I had to get a copy of everything and file it myself. Surprise, what I filed was denied, based on the fact that the documentation, that x ray as a matter of fact, didn't support the need. I looked into the condition a little more and I'm pretty sure they are right and the dentist was offering me something more on the cosmetic side than on the "necessary" side. Lesson learned: Should have gotten a second opinion on that much work, should have gotten the work pre approved. Pediatricians don't make more money by recommending tonsillectomies, but dentists do make more money recommending $$$dental work.

4. Pick up three prescriptions at pharmacy. Clerk gives me only two prescriptions in three bags and we both sign off on it.

Here's what happened: One bag was empty but marked "fridge"with a prescription label stapled to it, the second bag had the refrigerated prescription but otherwise no label, the third bag stapled shut had two different bottles in it and two different prescription labels stapled to it. Turns out it was a single prescription in two different bottles. I didn't realize the mistake until I got home. Went back to the store and the clerk gave me lots of flak. Had to come back a third time with all the bags to explain it, and there was not room for a third bottle in the overstuffed bag. She rolls her eyes and told me "it was possible" before giving me the prescription. Thank goodness it was something lame and not painkillers or I never would have been believed.

I only see the mistakes that cost me. I have no way of knowing about the mistakes that have been to my benefit that the provider eats, but I assume that the mistakes must go both ways.

Profiting off sick people

Random blog comment:

I'm just glad I don't have to suffer your system. Sweeping reform seems in order. I cannot for the life of me understand why anyone would accept a system where insurers can profit off sick people.

Sick people represent actuarial losses, not profits.

Crohn's and Thickened Blood

Two years preceding my Crohn's diagnosis I had muscle spasms, numbness and tingling in my hands, feet, arms, and legs and for the first time I also developed sharp pains in my calves. Neurologist did the mega workup and nothing turned up in the blood work.

Thromboembolic disease is a significant cause of morbidity and mortality in inflammatory bowel disease (IBD). A hypercoagulable state exists in IBD which may involve many components of hemostasis and is closely linked to disease pathogenesis.

It's time for me to go back and revisit all that blood work at next GI appt since the symptoms are back. Need to scrape together the deductible first. (Thanks to the dentist that did $2700 worth of unnecessary dental work not covered by my insurance and now I know about this thing called PREAPPROVAL)But I'm curious: If they could establish that I have thickened blood what could be done? Blood thinners with an ulcerated bowel?

Why don't insurance companies give more donations to politicians?

Here is the top 100 donors to Congress. You see the AMA, dentists, pharmaceutical companies. You see everyone that's going to make out like a bandit when reform passes. I see a single insurance company represented. If the big evil health insurance companies are so rich, why haven't they been the biggest donors?

House Speaker Nancy Pelosi ridiculed criticism by Republican Senate Leader Mitch McConnell of Democrats’ health-care plans, saying he’s echoing an insurance industry which makes “exorbitant profits” at the expense of Americans’ well being.

Why aren't they turning those exorbitant profits into massive donations like the other businesses do? The industry that's made the smallest donations is being singled out as the root of all health care woes.

Sacrifice, my butt.

KevenMD blogging about patient sacrifice required to reign in costs in abstract terms...

What if the pricey blue pill is actually better than the cheaper red one? What if it’s better but just a little bit? What happens when a yellow pill comes along, costing twice as much as the blue? What happens if there’s a new procedure that cures the ailment, but at an even bigger cost?

You healthy folks have the luxury of discussing this abstractly, but let's cut to the chase. Will I or won't I have to give up my no-side-effects Humira ($1600/month) and end up on Prednisone* ($16/month) instead? I've got a great GI that has kept me off that mess so far. What if in the long run prednisone and ostomies for prove to be cheaper than Humira for All? And if I make this sacrifice, what for? So someone else can get $30 off their next well baby visit?

Just sayin'

Nasty steroid side effects: high blood pressure, headache and muscle weakness. Prednisone also can cause puffiness of the face (moon face), growth of facial hair, thinning and easy bruising of the skin, impaired wound healing, glaucoma, cataracts, ulcers in the stomach and duodenum, worsening of diabetes, irregular menses, rounding of the upper back ("buffalo hump"), obesity, retardation of growth in children, convulsions, and psychiatric disturbances. The psychiatric disturbances include depression, euphoria, insomnia, mood swings, personality changes, and even psychotic behavior.

Blue Dogs Barking Up the Wrong Tree

"Poor people would get subsidies to help them buy care after spending 12% of their income on premiums, instead of 11% in the current bill."


The reformed reform plan is that an individual with a 50k income would need to come up with $5200 in premiums, no mention of deductibles, lowest tier in the exchange currently at 25% with out of pocket max of how much? Who can afford this? Why aren't HSA's considered?

I'm ready to get well now.

Daddy always used to say when I got hurt, "Think about how good it will feel when you get better." There is no getting better with this disease. It's not so much than any particular ache or inconvenience can't be handled, it's the day after day after day relentless nature of it that is like Chinese water torture.

Global payment = global pain in the butt?

Looks like fee for service didn't control costs in Massachusetts so they want to switch to paying docs per patient. If the doctor keeps the patient healthy he makes some money. Polticians must imagine that physicians have some kind of voodoo magic to make patients lose weight and quit smoking. Will they be able to fire a noncompliant patient? Will they be able to say that difficult cases are beyond the scope of their practice? Will they be able to turn down a patient's 732,930th request for an appointment for pain killers, loneliness, or that disturbing ache in the pinky finger?

This brings to mind the schemes that are put in place in prisons to keep food budgets under control. If a warden keeps the budget down he's allowed to personally pocket some money.

In Alabama earlier this year, a federal judge ordered the Morgan County sheriff locked up in his own jail for contempt for failing to adequately feed his inmates. Alabama allows sheriffs to keep food money they do not spend, and the sheriff reportedly pocketed more than $200,000 over three years.

Well, I'm not going to be one of those people that a doc can keep healthy. I'm not sick because I'm fat, I don't have hypertension or diabetes or any other "lifestyle" disease, I have Crohn's and I'm going to be a big pain in the butt to treat for any doctor who is rewarded for healthy patients. Perhaps one of the ways that a GI will be able to save a little money from me is to not use conscious sedation during a colonoscopy , an oft repeated event in the life of a Crohn's patient.

Colonoscopy without sedation is common in Europe and Asia, and efficacy is
comparable."There have been several studies that show that if you have motivated patients, a significant fraction of them can have a colonoscopy without sedation," said Douglas Rex, MD, past president of the American College of Gastroenterology

That's right, folks, lack of sedation is one way to keep costs down. We might quite literally take this one up the ass if it becomes national policy.

Enjoy those govt provided "free" well baby check ups.

Don't bother with doc says NHS.

I make the rounds to various international newspapers and saw this advice in today's Telegraph on how to handle swine flu:

Official advice is stay at home and log on to the NHS Direct website, consult
the Swine Flu Information Line (08001 513 513) or your GP for advice by phone.

If swine flu is confirmed as a phone diagnosis, then
you will be given an authorisation voucher - this means someone who can act as
your 'flu friend' can collect it from your GP's surgery and take it to a chemist
to pick up Tamiflu (or the alternative anti-viral relenza, if you cannot take
Tamiflu, for example because you are pregnant).
'Avoid going to your GP surgery.There may be people in the waiting room with underlying health issues for whom swine flu could be very dangerous,' says Dr Baker.


Read more:
http://www.dailymail.co.uk/news/article-1199760/SWINE-FLU-Your-vital-questions-answered.html#ixzz0LQzM0YON

Is it even legal in the US to make diagnosis by phone? I have a low level UTI right now and I'm pretty sure I'm going to have to pay the $150 for the doctor visit that is required so that I can get the $4 cipro from WalMart. Just seems like there is a lot we could do to lower costs in the US without disrputing the lives of patients and the livelihoods of providers.

Govt should pay my bills so that I can have fun!

Tim Egan's opinion piece in the New York Times informs us that we wouldn't have to work in unfun jobs if it weren't for those pesky bills.

We all know somebody who is sticking with a lousy job because of the health care. Economists call this “job lock,” and it stifles entrepreneurship and mobility, among other things.

We may also know someone who has remained married to the wrong person for the same reason. Call this “marriage lock.”

http://egan.blogs.nytimes.com/2009/07/15/health-cares-historic-moment/

No worry about high taxes preventing financial independence, all this health coverage will be free or a "small increase in taxes." Once we get rid of those high salaried CEOs helath care will only cost $1 per member per month, don't you know?

Humira ceases to work?

Daily I've been getting more fatigue and more joint pain. Yesterday I felt aches and pains as if I had been beaten up and I wonder what the game plan is if the Humira stops working altogether. My usual modus operandi is to let everything get intolerably bad then call up the nurse at the office.

Meanwhile at the national level the health care coverage debate rages on and as a patient I have no idea what fate befalls me a few years from now.

An enlightened comment

Sometimes the comments are more interesting than the articles. This one is to a WSJ article:

In my opinion, we should go to a "single payer" model where people pay for their primary care, much the way you might pay for a haircut or an oil change. For more expensive procedures, people should pay for at least some of the cost. Eventually, comparison shopping and the sheer pressure of people choosing to die rather than be bankrupted will force the prices down to a more rational level once again.

I got $100,000 in the bank, but I think I'll choose to die rather than spend it on medical care. Is that what would motivate the "choice"? A single payer system isn't needed for this scheme. As it is there are a few people forgo insurance and die, doesn't bring costs down.

An Extraordinary Belief

New York Times David Leonhardt says US health care system broken because of prostate cancer treatment. Or all the diseases he could have chosen! The US is ranked number one in prostate cancer survival rates, Leonhardt ignores this entirely and claims that it's prostate cancer treatment that is driving up the price of health care, actuaries would say the chronic diseases obesity and smoking cause are the lionshare's of their claims.

The most popular readers comments are always entertaining:

"Private insurance is the extraordinary belief that for-profit entities, with profit as their sole motive, will somehow provide good health care for the benefit of all".

Extraordinary claims require extraordinary evidence: The US has possesses the leading technology with the success rate to back it up. I'll go a step further for these skeptics: Private grocery stores is the extraordinary belief that for-profit entities, with profit as their sole motive, will somehow provide good clean food for the benefit of all.

French Health Care

This does not inspire confidence.

"Like Medicare in the United States, French NHI provides a great degree of patient choice."

http://www.ajph.org/cgi/reprint/93/1/31.pdf

Will "public option" really pay for the meds of the chronically ill

Sometimes govt insurance just doesn't pay for what you need. Two shots of Humira run my insurance co about $1600/month.

But several of these medications are expensive and can be difficult to get if a person doesn't have private drug insurance, said Dr. Kenneth Croitoru, a gastrointestinal specialist and researcher at Toronto's Mount Sinai Hospital. Although provincial government programs cover the costs of some of these drugs for individuals without private insurance, the programs don't cover some of the drugs that work best in people with IBD.

Bear in mind that 2 shots per month is the lowest or maintenance dose for Crohn's.


LINK