Consumers find it hard to determine how much a drug regimen would cost them

April 11, 2011

My wife and I don’t want to add to the nation’s financial woes. We understand why it’s important for us to take responsibility for managing our use of the health-care system, why we should limit ourselves to necessary expenses. Not only is it in the country’s economic interest, it’s also in ours: Our health plan is structured so that any medical excesses come out of our own pockets.

Now here’s the $2.5 trillion-a-year question: How can we make wise choices about how much to spend on health care if we can’t easily find out the cost of a simple medical procedure? It shouldn’t require more than a dozen phone calls and hours of time — not to mention a hunting dog’s single-mindedness — to piece together an accurate estimate for a recommended treatment.

But that’s precisely what happened to us in January and February.

If you work in the White House, on Capitol Hill or anywhere in the health-care industry, which now consumes about 17 percent of the nation’s gross domestic product, perhaps our micro-example brings a little bit of the real world into the debate. Consider it one citizen’s attempt to make a difference.

Our story begins with a diagnosis (osteoporosis) and a choice of what to do about it. Several years ago, a bone scan revealed that my wife, Mary Jo, had lost enough density in her spine and hip areas to suggest that she had a slightly higher risk of fractures than other women of her age (early 60s). It’s a consequence of aging, so she has a lot of company: According to National Institutes of Health estimates, more than 8 million older women and 2 million men have bone-density measurements that qualify as osteoporosis, with millions more heading in that direction. The NIH attributes 1.5 million fractures annually to weakened bones.


(RONALD CALA FOR THE WASHINGTON POST)

For years, Mary Jo had been taking daily calcium supplements and Vitamin D, but our family doctor wanted to do more. She prescribed Fosamax, a once-a-week tablet that can help slow or halt bone loss. It has since become available in its generic form, alendronate sodium.

The current cost to us under our insurance plan’s pharmacy benefits for generic drugs: $80 annually. A bargain, if it worked.

Mary Jo wasn’t keen on signing up to take a medication for the rest of her life. In the end, though, she decided to give it a try.

Mixed results

The regimen for alendronate sodium is trickier than for many other drugs. You not only have to remember to take the pill on the same day each week, but it must be swallowed whole on an empty stomach, first thing in the morning, with at least six to eight ounces of water. For 30 minutes after consumption, no lying down or eating. The worry: damage to tissue in the esophagus on the way down. For the same reason, the pill cannot be chewed.

Not exactly a user-friendly routine for a weekday work morning. Mary Jo chose Sunday as swallowing day, a schedule she kept for the next four years.

Her subsequent bone scans yielded mixed results. At best, the treatment was slowing the decline. At worst, it wasn’t having much effect.

When her most recent scan came back with the same ambiguous results except for one of her hip numbers, she began questioning the medication’s value for her, in part because she had been wondering whether it was a contributing factor to several months of on-again, off-again gastric distress. But it was hard to know whether the drug was working without stopping it entirely, waiting a year and then comparing her next scan with previous ones.


(RONALD CALA FOR THE WASHINGTON POST)

Our family doctor wanted Mary Jo to consult a specialist before making a decision. The specialist agreed that her density numbers could be better and suggested a newer medication that she thought might be more effective: Reclast, approved by the Food and Drug Administration since Mary Jo’s original diagnosis.

Reclast also offered a major practical advantage: It is given just once a year, by intravenous infusion, typically at a hospital’s outpatient clinic. It takes 15 to 30 minutes and, as with any medication, there are risks. Before the injection, blood tests are required to make sure the patient’s kidneys are not vulnerable to damage, one of the nastier possible side effects.

Once a year vs. once a week? Worth exploring, certainly. One big question: How much more than $80 a year would this trade-off cost?

The quick answer: No one could tell us.

Financial incentives

Almost without exception, everyone we asked — at the doctor’s office, the hospital financial office, the infusion center, our insurance company and the “Reclast Patient Support Network” (at the drug’s maker, Novartis) — was unfailingly patient and willing to help. What they lacked was clarity. Either they didn’t know the answer and had to refer us to another office, or what they told us turned out to be incomplete and, occasionally, incorrect.

The infusion center informed us, twice, that the total cost would be $300. “That’s everything,” we were told.

No hospital charge? Nothing for overhead, administration?

“No, that’s it,” was the reply. “There’s no extra charge for a doctor. We do it all here.”

We didn’t want to be surprised by a big bill at the end, so Mary Jo kept making phone calls while we awaited our insurance company’s pre-certification to proceed. We’re insured through one of Aetna’s “consumer-directed health plans,” the Aetna HealthFund. In recent years, private employers have embraced these plans as a way to cut rising costs.

It works like this: At the beginning of each year, we receive a set amount ($750 each for 2011) in our account, and we’re responsible for paying our medical and pharmacy bills from that $1,500 until it is exhausted. (We also pay a hefty monthly premium.)

If we stay within Aetna’s network of providers, we pay less — because Aetna has negotiated deals with providers for each type of charge. In other words, the insurers and providers know precisely what every procedure costs. Only consumers remain in the dark.

Once the HealthFund is depleted, we’re responsible for 100 percent of most charges (excluding hospitalization) until we satisfy one of our deductibles, which is $3,500 each or $4,750 combined. After that, a co-pay arrangement kicks in, until we reach our $6,000 out-of-pocket maximum. At that point, the plan covers all expenses. As you can see, it’s very much in our economic interest to hold down what we spend.

In early February, Aetna approved the infusion. The next day, we got a surprise phone call.

“Hi, I’m from the Aetna Specialty Pharmacy,” the caller said. “We’re ready to ship your medication.” He wanted to confirm the address on his order form.

It was our home address.

“Whoa,” I said. “No one had told us that the medication would come here. Does it need to be refrigerated? Why would you send it to our house?” I had assumed the medication was included in the infusion center’s “that’s everything” package.

Now it was the Aetna caller’s turn to be confused. We agreed that his first move should be to check with the infusion center and the specialist.

“Just out of curiosity,” I said, “how much does the medication cost?”

Silence while he looked. “$1,113.20,” he replied.

I made a noise that might have sounded like a gasp.

“Don’t worry,” he said, cheerfully. “It’s covered 100 percent.”

I was dubious. I said, “We were told this isn’t covered as a pharmacy benefit, because the infusion is considered a medical procedure. If that’s right, then we will pay all the costs out of our HealthFund.” I went on to explain that the $1,113 plus the $300 infusion-center charge would wipe out our $1,500 for the year.

He said he didn’t know what would be covered. His job was to check on sending out the medication. Compartmentalization. He wasn’t the first person to tell us something incomplete, and he wouldn’t be the last.

The rest of the story

Our skepticism now justified, we intensified our efforts to pin down the exact cost. Another round of phone calls produced more conflicting information. One thing we learned for sure: The infusion center would order Reclast from the hospital pharmacy, and it would cost $200 more than the Aetna Pharmacy price.

Why didn’t our earlier phone calls elicit this information? Again, compartmentalization: The infusion center wouldn’t be billing us for the Reclast, therefore it wasn’t factored into the $300 price. We learned this from the hospital’s financial center.

That prompted another call to Aetna, to see if the hospital could submit the Reclast order as a pharmacy charge. My argument: When I typed “Reclast” into Aetna’s “Price-a-Drug” online cost calculator, the digital estimator treated it as a covered expense under our plan. Cost: $70.

No such luck. We would be on the hook for the entire $1,300, the Aetna representative said, because a Reclast infusion was considered a medical procedure.

That made the decision easy. Weighing the $1,600 cost vs. the likely benefits, Mary Jo opted not to go ahead. She also decided to go a year without any medication. She would keep to her routine of calcium and Vitamin D supplements, weight-bearing exercises and good diet, and then see what her next scan showed.

Making health-care choices isn’t easy, particularly when it comes to such intangible benefits as reducing a risk that’s already hard to quantify. Ambiguity comes with the terrain — which is why the health-care system shouldn’t add to the confusion.

Of course, it’s hard to predict every eventuality. A surgery estimated at two hours could turn out to be much longer if complications arise. But Mary Jo and I weren’t asking for a guaranteed price, just the basic one. Yes, insurance plans vary, but aren’t computers good at storing data, sorting it out and calculating bottom lines?

The medical world does not have the equivalent of a restaurant menu or an auto mechanic’s estimate. You might scoff at comparing health care to eating out or fixing a car, but think about it: If we consumers are expected to take charge of our health care, we need a one-stop place to find out the itemized cost of various choices. Otherwise, the idea of “consumer-directed health care” is little more than euphemistic pretense.

That’s hardly what the doctor ordered.

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