Our **ed-up healthcare system

If you've followed my blog from the start, you may recall that I had a brain MRI in Germany. It cost 843 Euros, or less than $900. (We paid the full cost out-of-pocket and were reimbursed 100%.) When we told the staff how much an MRI in the US costs, they were incredulous.

Earlier this week, I paid for my portion of the MRI I had last month. It cost nearly $11,000 dollars, of which I paid $461. 

But wait, there's more. 

Before I met my deductible earlier this year, I discovered that I was paying $126 per month for the large (at-home) oxygen concentrator that I haven't used in about 15 months. (After I hit my deductible, I pay 10%, or $12.60. My portable costs $36 before deductible and $3.60 after, so $16/month total.) I asked my pulmonologist to write a script indicating that I only need the portable concentrator (for exercise) and don't need the large concentrator. (You can't get a portable anywhere--used or new--without a prescription, so I can't just go buy one on Amazon or eBay.) 

Long story short, PSU's Highmark concierge, who often investigates these problems for me, was told by the oxygen supplier that they are a package deal: you can't have the portable unless you also have the large concentrator. Why? Because otherwise they wouldn't make enough money!!!!! They admitted this to her.

Imagine going to CVS to get a prescription for, say, amoxicillin. It comes to $5. But then they tell you, "You also have to order this other antibiotic for $20, even though you don't need it. Otherwise we wouldn't make enough money. So if you want the amoxicillin, you have buy buy this other medication, too."

That is what these oxygen companies are doing. The Highmark concierge called around to see if any other suppliers would provide only the portable concentrator. Nope. They all operate this way -- essentially stealing money from insurance companies, employers, patients, and the public.

This system is so ass-backwards: forcing people and insurance companies to pay for treatments/supplies that aren't needed. So I've been paying, and will continue to pay, about $375 per year for an apparatus that is just sitting in the basement collecting dust. 

***

This year I'm serving as a Faculty Senator on the Faculty Benefits Committee, which pertains to health insurance, among other benefits, for all employees (except for unionized Teamsters). I was dismayed to learn that HR is considering requiring prior authorization for advanced imaging such as CT scans, MRIs, and PET scans. I obviously have a personal stake in this, but more importantly, research shows that in many cases, prior auth delays, interrupts, or denies care, resulting in worse health outcomes (not to mention bureaucratic headaches for doctors). 

This is a hill I will die on. (Note to self: cut back on # of hills I will die on.) I've learned that research shows there are some conditions, such as orthopedics (e.g., knee or back pain), where early advanced imaging doesn't lead to better outcomes. So prior auth would make sense in those cases. I'm working on plans to demand/request that HR get data from Highmark about their prior auth plan and whether it would apply to advanced imaging for certain conditions or all conditions, including cancer, as well as the denial rates and reasons and how many appeals are overturned. In true Penn State fashion, the document discussing the proposed changes is confidential...but that doesn't mean I can't talk about it.

Since I was in Germany when I was diagnosed with lung cancer, I didn't need prior auth for anything (we paid everything up-front and were then reimbursed). When my doctor said I should get a CT scan, I just went down the street to the nearest imaging clinic. My doctors at the LungenClinic didn't need prior auth for the CT scans, MRI, or genetic testing. I wonder how long my diagnosis and treatment might have been delayed if I'd been in the US. One reason we decided to stay in Germany for my treatment rather than flying home 6 weeks early is that I could start targeted therapy just 2 weeks after my biopsy--and that is exactly what happened. I could be wrong, but I cannot imagine that quick of a timeline happening here.