Nearly lost it looking at my Medical Explan. of Benefits

[kickingandscreaming]

I have a Medicare Advantage HMO plan and I don't usually read the EOBs I get each month. Today I did.  And I nearly had a stroke!

Do you know how much my dialysis clinic bills for one session of in-center Hemo?  Hold on to your hat.
Amount Providers Have Billed the Plan: $4,181,13  then for some reason it went up to $4,4 73.81
Amount plan approved:  $276.14

For PD--one day:
Amount billed:  $1,938.43
Amount paid: $334.52

For PD training-- one day:
Amount billed $4,642.30
Amount paid: $334.52

So for the month of March for Medical and Hospital Claims (not drugs):
Amount billed: $135,513.68
Amount paid:  $26,290.91

Ye Gods!! is all I can say.  Well, I guess I can also say am I worth this YUGE expenditure of $$$$$$$?!    I can't imagine that I am.

[hatedialysis2]

KS your bringing out the ranting mode in me today..  This topic gets my blood boiling

Our healthcare system is ripping off tax payers and will bankrupt us and our future generations.   It does not cost that much for us to do our own dialysis without doing any math.  Although I would love to know how much it really costs.   How can we fix this, what do responsible citizens do?  Write a petition. And jeopardize our treatments and for others?  There's got to be a smart way of doing this.  Do I have to be unde the care of a  clinic?  Why not just a doctors office.  My dietitians serve no purpose, the should be on an as needed basis.  What about social workers, other than help if you are traveling, I personally don't need to have him pop his head once a month to hello during my clinic visit. 

[Michael Murphy]

What you are seeing is the three tier costs of Dialysis.  The first is the base cost which is the 4400 dollar level this is what is billed to the uninsured.  The second is the negotiated rate private insurance pays. It tends to be about 1/3 of the base rate.  What this means when the 4400 dollar bill at base rate is not payed the provider get a tax loss of 4400 which generally generates a tax return of about 1/3 base rate. Third and last is the Medicare rate which is set by Medicare and that is the 276 dollars you saw.  What's really funny is you would think at Medicare rates the provider would loose money but the rate is calculated to cover costs and provide a modest profit.  If you started dialysis on private insurance this explains why they were so happy that you joined the club.
Some providers claim they loose money on Medicare if that was true why would they advertise for Medicare patients.

[Simon Dog]

It is possible for the providers to be telling the truth that they lose money on Medicare patients and still make money on them - it's all a matter of Clintonesque newspeak.

Like many businesses, there is "fixed overhead" and "incremental cost".   It is quite possible that the clinic makes an incremental profit on each additional medicare patient, but would not even break even if all patients paid at the Medicare rate.

In my case, private insurance paid about $450; Medicare about $250 (per hemo treatment).   Treatment at clinics outside my HMOs area of coverage, but paid by the HMO at the excessive "asking price" have ranged from $3000 to $5050.  Now that I am on Medicare, the clinics I visit as a transient get the Medicare $250, plus the MD gets $8 per treatment to write the orders.

I have a Medicare Advantage HMO plan and I don't usually read the EOBs I get each month. Today I did.  And I nearly had a stroke!

You only qualify to Medicare Advantage because you had it before starting dialysis.   If you started dialysis before Medicare, you'd be forced to traditional Medicare.

Do I have to be unde the care of a  clinic?  Why not just a doctors office

Even if you do home hemo, you need a clinic so you have a place to go if you need in-center (temporarily infirm, having fistula problems, etc.).

[hatedialysis2]

I found an old link from 2006 on this forum stating the cost to the clinic per month for Nxstage equipment and supplies
"
NxStage says it has developed an economic model that will work. The company charges $1,500 a month for the rental of equipment and supplies, which NxStage chief executive Jeffrey H. Burbank said is enough to provide a dialysis clinic supervising an in-home program the same profit that a clinic-based patient would generate". http://ihatedialysis.com/forum/index.php?topic=1120.0

If I remember correctly, my Medicare and supplementary pay around $8000 per month for me to do my own dialysis.  This does not include the nephrologist monthly fee.    if Nxstage monthly cost has not change then my clinic is making a profit of about $6500 per month minus ancillary supplies for my treatments.

As far as belonging to a clinic versus just seeing a nephrologist once a month, all other duties of a social worker and dietitian can be on a case per case as needed.  My dietitition does not do anything for me other than hand me monthly labs with happy face stickers. Certain patients need more hand holding  and some you just have to pray for cause they assume dialysis and pills will take care of the junk they eat.   In case of an emergency requiring me to go in-center then the doctor can just refer me to one of the centers he/she owns or is affiliated with.     

Would that cut costs without sacrificing the great quality of care we receive? Or is it too simplistic.  I'm in the Donald Trump solving mode

[Simon Dog]

Fresenius owns, rather than rents, the NxStage machines they issue.  They are, however, on a maintenance/support contract which contributes to cost.

The "load" allowed for one home care RN is about 12-15 patients.   If the fully burdened cost is $75K, this means a minimum of $5K for the nurse alone.  The total cost for one RN is probably more than $75K, plus clinics rarely run with all home care nurses running at full capacity.  The clinic I use has about 15 home patients and two home care RNs, which means $150K RN cost (using my guesstimate), or $10K per patient for nursing services alone.

Sometimes the MD really earns that monthly fee.  I had two months where I needed a medical consult with the MD after each dialysis treatment (first, it was adjusting HGB to get read for surgery; afterwards, it was adjusting my EPO dose and monitoring my INR to adjust the coumadin dose.

I felt a bit like Bob P when I stopped at the local hospital for my platelet labs (I was doing this 2x/week for a month prior to surgery).  The first time I walked in with the light blue tube and the MD lab requisition and got "what's this?".  A blood sample.  "No, where is it coming from".  My arm.  Oh, you mean my home.   "What?".  Sure, haven't you read about those home phlebotomy kits on Amazon?  Once they knew the drill, it was easy.    It was easy calling the lab for results - I never formally introduced myself, so they started talking to me about "your patient" (i.e., me).  I learned to refer to myself in the third person.   Once again, I felt like Bob P all over again.

As to decreasing cost - more home care.  Home dialysis is cheaper, assuming the patient survives long enough to amortize the cost of the training.

[Michael Murphy]

I just joined a Medicare advantage program, I have been on Dialysis for 36 months and joined Medicare in January.  When you first become eligible I think you get 6 months to join a medigap or advantage program after that window it becomes more difficult.  I was lucky my wife who just retired company want every one to join Medicare so they offer a highly subsidized advantage program, with a enhanced prescription plan.

[Jean]

Just last month Scan, which is a medicare supplement plan started sending us breakdowns of the cost of for instance blood draws. Holy Crap. One little stick, 5 or more vials and my blood tests run oh, about a thousand dollars. Wowie!! So, 4 times a year is $4000.00 a year for 8 years, $32,000.00 just for my blood work. And I am not even on D yet. I think I will keep track to see how much this costs John Q Public over the course of the disease.

[Rerun]

There is no truth in billing.  That is our health care system's WHOLE DAMN problem.  They won't tell what something or some service really costs.  They Lie.  Then it is all over the board.  Medicare keeps things real.  One of my recent monthly EOB went up to 75,000 dollars for one month.  BS.... Medicare said Ahhh Dahhh NO  $3,000 (or there abouts)

I am a Conservative Republican and all that, but I do believe in a one payer system and it should be Medicare.

A trip to ER for a broken arm $6,000  Medicare would say Ah Daa NO.... $600.   

Back in 1961 in Seattle, WA you had to come up with $10,000 for 2 years of dialysis.  That would be about $400 a month.  Technology has changed for the better and cost of living has changed but $400 a month to $70,000......?  I don't think so.

[Simon Dog]

Back in Seattle in 61, you not only had to come up with $10k/year, but had to be chosen by a committee that allocated scarce dialysis seats.  Google "Seattle death panel".

Similar decisions are now being made as to whom gets Harvoni for Hep-C (at $95K for a course of treatment).  One Boston area insurance company just announced it changed its policy so you no longer have to wait until you liver is nearly shot to qualify for the drug.    This is going to cost them a bundle as Hep-C patients switch at open enrollment.  Interestingly, Fresenius now covers the  cost of the Hep-C treatment if you get infected in their clinic (mighty sporting of them).

The system would not survive if everyone who pays now paid the medicare prices.   It's a transfer payment system with Medicare basically covering incremental cost.   One big flaw is that medicare is not allowed to do any negotiation regarding drug prices.

has changed for the better and cost of living has changed but $400 a month to $70,000......?  I don't think so

According to http://www.usinflationcalculator.com/ $10,000k in 1961 dollars is $79.6k at current valuation.   Since the $10k was 2 years, this is roughly a doubling in real cost as dialysis moved from a lab experiment to big business.

[kickingandscreaming]

One big flaw is that medicare is not allowed to do any negotiation regarding drug prices.

Thanks to the GOP Congress that passed the Medicare Part D bill--written entirely by the Big Pharma lobbyists.  It's bad policy and bad economy.

“The drug companies say they must impose higher prices in the U.S. to pay for research that enables them to innovate and develop new drugs that save our lives. But that’s not true. Half of the scientifically innovative drugs approved in the U.S. from 1998 to 2007 resulted from research at universities and biotech firms, not big drug companies, research shows. And despite their rhetoric, drug companies spend 19 times more on marketing than on research and development.”  Healthcare for America Now
 http://www.ncpssm.org/EntitledtoKnow/entryid/2061/negotiating-for-lower-drug-costs-in-medicare-part-d

How much could Part D save? The Congressional Budget Office says that simply giving Medicare's low-income beneficiaries the same discount available under Medicaid would save $116 billion over 10 years — serious savings that could cut the cost of the program by roughly 10% a year. By some calculations, extending Medicaid-style savings to all 35 million of Medicare's Part D beneficiaries could save an additional $39 billion over 10 years.

http://www.usatoday.com/story/opinion/2014/04/20/medicare-part-d-prescription-drug-prices-negotiate-editorials-debates/7943745/






Edited: Fixed quote tag error- kitkatz-Admin

[hatedialysis2]

The markup rates for pharmaceutical drugs is outrageous.  They get to poison us and rip us off at the same time.  Many of these drugs can be substituted with diet, life style , and occasional god created balanced herbs and supplements.     Below is a link from  http://www.rense.com/general54/preco.htm  titled "The TRUE Cost of Your Prescription Drugs!"
__________________________________________________________________


The TRUE Cost Of Your
Prescription Drugs!
Material Costs of Medical Compounds
Investigative Research Reveals the True Costs of Drugs
 
By Sharon Davis and Mary Palmer
US Department of Commerce
7-3-4
Note: This Information has Been Widely Disputed.
See http://www.breakthechain.org/exclusives/genericrx.html

 
The women who wrote this email and signed below are Federal Budget Analysts in Washington, D.C.
 
Did you ever wonder how much it costs a drug company for the active ingredient in prescription medications? Some people think it must cost a lot, since many drugs sell for more than $2.00 per tablet. We did a search of offshore chemical synthesizers that supply the active ingredients found in drugs approved by the FDA. As we have revealed in past issues of Life Extension, a significant percentage of drugs sold in the United State contain active ingredients made in other countries. In our independent investigation of how much profit drug companies really make, we obtained the actual price of active ingredients used in some of the most popular drugs sold in America.
 
The chart below speaks for itself.
 
Celebrex 100 mg
Consumer price (100 tablets): $130.27
Cost of general active ingredients: $0.60
Percent markup: 21,712%
 
Claritin 10 mg
Consumer Price (100 tablets): $215.17
Cost of general active ingredients: $0.71
Percent markup: 30,306%
 
Keflex 250 mg
Consumer Price (100 tablets): $157.39
Cost of general active ingredients: $1.88
Percent markup: 8,372%
 
Lipitor 20 mg
Consumer Price (100 tablets): $272.37
Cost of general active ingredients: $5.80
Percent markup: 4,696%
 
Norvasec 10 mg
Consumer price (100 tablets): $188.29
Cost of general active ingredients: $0.14
Percent markup: 134,493%
 
Paxil 20 mg
Consumer price (100 tablets): $220.27
Cost of general active ingredients: $7.60
Percent markup: 2,898%
 
Prevacid 30 mg
Consumer price (100 tablets): $44.77
Cost of general active ingredients: $1.01
Percent markup: 34,136%
 
Prilosec 20 mg
Consumer price (100 tablets): $360.97
Cost of general active ingredients $0.52
Percent markup: 69,417%
 
Prozac 20 mg
Consumer price (100 tablets) : $247.47
Cost of general active ingredients: $0.11
Percent markup: 224,973%
 
 
Tenormin 50 mg
Consumer price (100 tablets): $104.47
Cost of general active ingredients: $0.13
Percent markup: 80,362%
 
Vasotec 10 mg
Consumer price (100 tablets): $102.37
Cost of general active ingredients: $0.20
Percent markup: 51,185%
 
 
Xanax 1 mg
Consumer price (100 tablets) : $136.79
Cost of general active ingredients: $0.024
Percent markup: 569,958%
 
Zestril 20 mg
Consumer price (100 tablets) $89.89
Cost of general active ingredients $3.20
Percent markup: 2,809%
 
Zithromax 600 mg
Consumer price (100 tablets): $1,482.19
Cost of general active ingredients: $18.78
Percent markup: 7,892%
 
Zocor 40 mg
Consumer price (100 tablets): $350.27
Cost of general active ingredients: $8.63
Percent markup: 4,059%
 
Zoloft 50 mg
Consumer price: $206.87
Cost of general active ingredients: $1.75
Percent markup: 11,821%
 
Since the cost of prescription drugs is so outrageous, I thought everyone I knew should know about this. Please read the following and pass it on. It pays to shop around. This helps to solve the mystery as to why they can afford to put a Walgreen's on every corner.
 
On Monday night, Steve Wilson, an investigative reporter for Channel 7 News in Detroit, did a story on generic drug price gouging by pharmacies. He found in his investigation, that some of these generic drugs were marked up as much as 3,000% or more. Yes, that's not a typo ... three thousand percent! So often, we blame the drug companies for the high cost of drugs, and usually rightfully so. But in this case, the fault clearly lies with the pharmacies themselves. For example, if you had to buy a prescription drug, and bought the name brand, you might pay $100 for 100 pills. The pharmacist might tell you that if you get the generic equivalent, they would only cost $80, making you think you are "saving" $20. What the pharmacist is not telling you is that those 100 generic pills may have only cost him $10!
 
At the end of the report, one of the anchors asked Mr. Wilson whether or not there were any pharmacies that did not adhere to this practice, and he said that Costco, Sam's Club and other discount volume stores consistently charged little over their cost for the generic drugs. I went to the the discount store's website, where you can look up any drug, and get its online price. It says that the in-store prices are consistent with the online prices. I was appalled. Just to give you one example from my own experience, I had to use the drug, Comparing, which helps prevent nausea in chemo patients. I used the generic equivalent, which cost $54.99 for 60 pills at CVS. I checked the price at Costco, and I could have bought 100 pills for $19..89. For 145 of my pain pills, I paid $72.57. I could have got 150 at another discount store for $28.08. I would like to mention, that although these are a "membership" type store, you do NOT have to be a member to buy prescriptions there, as it is a federally regulated substance. You just tell them at the door that you wish to use the pharmacy, and they will let you in. (This is true, I went there this past Thursday and asked them.)
 
 
I am asking each of you to please help me by copying this letter, and passing it into your own email, and send it to everyone you know with an email address.
 
Sharon L. Davis
Budget Analyst
U.S. Department of Commerce
Room 6839
Office Ph: 202-482-4458
Office Fax: 202-482-5480
Email Address:
 
Mary Palmer
Budget Analyst
Bureau of Economic Analysis
Office of Budget & Finance
Voice: (202) 606-9295
Fax: (202) 606-5324
 
http://www.sonomavalleyvoice.com/articles.php?id=411


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[kickingandscreaming]

In our independent investigation of how much profit drug companies really make, we obtained the actual price of active ingredients used in some of the most popular drugs sold in America.

Although there IS an enormous ripoff taking place in the drug business, it isn't really fair to base price just on the cost of ingredients.  Even though the drug companies exaggerate their R & D costs, there still are a lot of R & D costs and that is intellectual property and labor and risk and investment-- all of which add big layers of cost to the final product.  The system is clearly broken, but it's not fair to judge it entirely by cost of ingredients.

We should all be very concerned about the (hopefully not coming) Trans-Pacific Partnership, the so-called trade deal that Obama is pushing very hard.  It's a disaster in the making and one of the places where it will be felt is in the cost of generic drugs which will get even more jacked up.  Tell your congress critters to vote "no" on the TPP.

The Trans-Pacific Partnership would provide large pharmaceutical firms new rights and powers to increase medicine prices and limit consumers' access to cheaper generic drugs. This would include extensions of monopoly drug patents that would allow drug companies to raise prices for more medicines and even allow monopoly rights over surgical procedures. For people in developing countries involved in the TPP, these rules could be deadly – denying consumers access to HIV/AIDS, tuberculosis and cancer drugs.

The TPP would also establish new rules that could undermine government efforts to contain rising medicine prices in developed countries like the United States. An analysis of the final TPP text shows taxpayer-funded public health programs would be exposed to pharmaceutical company attacks and constrain future policy reforms to reduce prescription drug costs for Americans. The text explicitly binds Medicare to TPP rules that would limit proposed policy changes to tamp down healthcare costs for seniors.

More at http://www.citizen.org/tpp-public-health

[hatedialysis2]

http://www.truth-out.org/opinion/item/16071-how-big-pharma-is-killing-americans

"Each year, millions of Americans are dealt the devastating news that they have cancer, and each year, millions of Americans, many of whom are uninsured, have to figure out how to pay for the life-saving treatments that they need.

And unfortunately, that decision can be a very hard one.

Thanks to America’s for-profit health insurance industry, prescription drugs are a big business.

In fact, in 2012, the top 11 global drug companies made nearly $85 billion in net profits.

They made these profits by slapping extraordinary price tags on the prescription drugs and health treatments that Americans are forced to rely on in order to survive devastating diseases like cancer.

But while drug companies have been largely able to get away with robbing Americans left and right for the past several decades, more and more people are speaking up about the outrageous costs of lifesaving treatments.

A group of more than 100 leading oncologists from across the globe have penned a journal article, announcing their plans to start a campaign to force drug companies to slash their profit margins.

In the article, the groups of oncologists ask, “What determines a morally justifiable price for a cancer drug? A reasonable drug price should maintain healthy pharmaceutical industry profits without being viewed as 'profiteering'.”

But cancer drugs aren’t the only drugs on the market that are gouging the wallets of Americans.

Last year, 11 of the 12 new-to-market drugs approved by the Food and Drug Administration were priced above $100,000 per-patient per-year.

And, Americans pay nearly 50% more for comparable prescriptions in the United States than they would in the UK, France, Germany, Spain and a host of other developed nations.

For instance, look at Nexium, a drug commonly prescribed to treat acid reflux.

In Spain, a prescription for Nexium costs, on average, $18. In France and the United Kingdom, Nexium costs, on average, $30 and $32 respectively.

But here in the United States, a prescription for Nexium costs, on average, a whopping $187, six times as much as it costs in France and the UK.

Lipitor is another commonly prescribed medication in the United States, used to treat high cholesterol. In New Zealand, a prescription for Lipitor costs, on average, just six dollars. And in South Africa and Spain, it costs $11 and $13 respectively. But here in the United States, a prescription of Lipitor costs, on average, $100.

These are just two of the commonly used drugs that are bankrupting Americans.

Other commonly used medications, like Nasonex, Cymbalta, Vytorin and Celebrex also cost far more in the United States than in other countries in the developed world.

Prescription drug pricing in the United States is unregulated, which means that Big Pharma can charge whatever it wants for prescription drugs.

If you ask executives at America’s top pharmaceutical drugs about the high costs of prescription drugs, they’ll tell you that high and increasing drug prices are needed to sustain research and development efforts. But numerous studies have debunked those claims.

One study, by the group Families USA, found that America’s major drug companies are spending more than twice as much on marketing, advertising and administration than they do on research and development.

The report also found, not surprisingly, that the total profits of America’s top pharmaceutical companies far exceed their research and development costs.

Make no mistake about it. Lifesaving medications and commonly prescribed drugs in America today are absurdly expensive here – and only in this country – because Big Pharma is ripping off Americans.

So what can we do about this? How do we drive down the costs of prescription medications?

Right now in Canada, drugs cost a fraction of what they do here.

That’s largely because in Canada, there is a single-payer insurance program that negotiates prescription prices.

As the group Physicians for a National Health Program (a group of doctors campaigning for a single-payer healthcare system) points out, when all patients are under one healthcare system, the payer, or the American citizen, has a lot more clout and influence over the pharmaceutical industry.

For example, the Veterans Administration gets a roughly 40% discount on prescription drugs because of its large buying power. Imagine if that buying power were spread to all Americans. Instead, Republicans put into Medicare Part D that it is illegal for Medicare to negotiate with the drug companies for discounts – they have to pay full retail.

Competition and negotiation – what some would call “the free market” - are the great fears of Big Pharma, and why Big Pharma is so opposed to a single-payer system.

But isn’t it about time that we put the lives of Americans ahead of the padded wallets of Big Pharma’s executives and stockholders?

It’s time to save lives.

We already have a single-payer non-for-profit healthcare system in America – it's called Medicare. All we need to do is reduce the eligibility age to birth, and give it the ability to negotiate prices with the drug companies.

I call it Medicare Part E – E for Everybody. It could be done with a two-page piece of legislation, and has been proposed repeatedly in Congress only to be blocked by Republicans.

Wake up your friends and neighbors and tell them about it, and call your legislators. Medicare for everybody!

This piece was reprinted by Truthout with permission or license. It may not be reproduced in any form without permission or license from the source."

[Michael Murphy]

Several years ago a family member without insurance needed  medication that at the time was 750 dollars a month, every month. I searched for a Canadian company and got a 3 month supply for 200 dollars.  What worried me was would the drug be good. The surprise answer was it was the same.  Not similar the same, same pill, Same packaging , same instructions. It turned out the drug company outsourced its manufacturing to India.  The old quote about the greatest thieves being in congress is wrong they now make drugs.  The only real answer is to remove patent protection if they want patent protection it must come with some protection against price gouging.

[Simon Dog]

It takes 95 pills of Harvoni to cure Hep-C.  In the US, it's $1000 per pill.  My MD tells me it's $4 per pill in India.   Insurance companies should start paying for business class airfare and suites at the Oberoi or Taj to get their patients to get their drugs in Bangalore.

The mindset of some pharma workers is incredible.  I met one who honestly believed that people going to Canada to buy drugs where "cheats" and "thieves".

[Fabkiwi06]

I just got my sheet for my prescriptions for the month. It's almost $2000 just for my Sensipar for a month. That's beyond ridiculous. I could live (meagerly) for almost 3 months on that. At least we all get Medicare and other programs to buffer the cost. I can't imagine how the Hep-C patients cope without.

I know no health care system is truly perfect, but it seems like every step forward our country tries to take with it, we end up two steps back.

[Simon Dog]

I just got my sheet for my prescriptions for the month. It's almost $2000 just for my Sensipar for a month. That's beyond ridiculous. I could live (meagerly) for almost 3 months on that. At least we all get Medicare and other programs to buffer the cost. I can't imagine how the Hep-C patients cope without.

I know no health care system is truly perfect, but it seems like every step forward our country tries to take with it, we end up two steps back.

If you are any private Rx plan, Sensipar will give you a pharmacy card to cover all but $5/month of the copay.   They don't do this for Medicare Part D patients since that is apparently prohibited by federal regulations.

As to Hep-C - no tickey, no washey.   Hep C patients won't die in the ER, so it's strictly CIA for treatment (Cash in advance).   Some people just have to live with it (or, more accurately, slowly die of it) because their insurance won't cover it.

[Fabkiwi06]

I think I pay about that right now. My social worker made sure of it before they put me on it.

It's ridiculous all the way around.

[iolaire]

Looked at my first month on Medicare , less three sessions where I was traveling.
Payment Summary
Total Amount Charged: $53566.62
Total Non-Covered Charges: $172.20
Medicare Approved: $53394.42
Medicare Paid You: $0.00
Medicare Paid Provider: $2362.94

Its even more unclear than with Aetna, but I like that lower paid provider number, well on Aetna that would have been over $15k for 10 sessions!  I can not see what was not covered on the Medicare site... But the MSN doesn show what was not approved but without prices.  It looks like either the 1 or 9 units of Epo is not approved and the other is, probably its the 1 because the non covered charges are so low.