Pretty simple, folks. Texans have had a really hard time this year, especially those on Aetna. The Affordable Care Act forced Aetna to get rid of a lot of the high-risk crappy plans, which is great. However, Aetna then turned around and raised all of their allowed prices on medication, procedures, and tests. They're also denying more care overall. They say this is an attempt to 'manage costs.' For those of us on a high-deductible, low premium plan, this is disastrous.
What this means is that the costs are being forced on to the consumer, which leads to people not taking their medication, not getting treatment, and not getting necessary tests, because they can't afford it. Even though they have insurance, and even though the doctor says this is the best treatment for their illness. Managed care means pushing the cost of expensive medications for rare diseases to the patients who are unfortunate enough to have them. The upshot of all this is that the insurance companies get what they wanted in the first place - not having to pay for medication and treatment for people with rare diseases.
Everybody who has Aetna has to wait until they hear that Aetna will actually pay for it. I'm in debt up to my eyeballs because of all the up-front costs I've had this year.
Those of us jammed in the gap (mind the gap!) between Medicare and a hard place are really struggling. Personally I don't have a choice between Aetna and another company, because insurance is provided by my employer. There are lots of other people like me, who have health care through their employer, but can't afford to go to the doctor. All because there is no regulation of the health insurance or pharmaceutical industry. Accepting Medicare funding in Texas would have also helped, but it wouldn't have solved the basic problem of the cost of health care.
One of the Democratic Party planks this year should be drastic health care industry reform. Costs keep going up for the consumer, while the insurance industry and the pharmaceutical industry are making record profits. If we want to motivate Texans to get to the polls in November, then we need to promise that this will get fixed.
And now for a personal rant about Aetna...
I am what the doctors call a complex patient. At least that's what it says on all the doctors' bills - complex visit. The last time I talked to my PCP was when I talked about getting pregnant, three years ago. I have multiple sclerosis, Reynaud's, no thyroid, no gall bladder, no appendix, and vascular insufficiency in my legs.
After having a blood clot in 2010, an emergency appendectomy in 2012, a gall bladder and thyroidectomy in 2013, I figured my medical problems were over. All the vestigial organs were out - what else could go wrong?
I got pregnant in May of this year. I contacted all my doctors and of course they all wanted to see me, some of them twice! For me, the priority was to go see my hematologist.
We decided to do some more complex testing on my blood. It turns out that I'm a heterozygous carrier for Factor V Leiden. This is a genetic mutation that causes the blood to be too enthusiastic about clotting.
Last year, because I'm poor, I opted for the cheapest health plan they had available through my employer, which is essentially a bronze plan with a bonus on top. I have a $4500 deductible before Aetna will pay their share of the costs. This means that all my specialist visits (my hematologist, my thyroid doctor, and my MS doctor) were all around $300 per visit until I hit the cap in July.
This was a real problem. I had to cancel some appointments because I just didn't have the cash. Paying for my medications was killing me! The cost of my Keppra prescription through Aetna was $240 for 90 days, $91 for one month. My Synthroid was $40 for a month, $107 for 90 days. (My doctor wanted me on the name brand, not the generic.) Flexaril is on the Walmart $4 plan, so at least that's cheap. If I ran it through my insurance it cost me more money than if I paid cash for it.
I was managing okay, even with the high price of my medications. I had to go without Synthroid for a week, which really threw off my levels, but I was able to find an online coupon for generic Keppra.
The hammer really came down when I got pregnant in May. The testing leading up to my diagnosis of Factor V Leiden was expensive - $100 or $200 at a pop (or stick.) With the Factor V Leiden, my doctor decided that I should be on a blood thinning medication. She prescribed Lovenox for me. 9 months of Lovenox at Aetna's prices is $5,292. So of course that was out. (I would have been through my deductible very quickly, but also $4500 in debt.) We went with heparin instead. Aetna will not pay for heparin, so the cost to me retail is $1200 a month. Crazy, right? It's like they're trying to kill me or drain me of all available funds. I was able to find an online coupon for heparin, and now I buy it from CVS for $75 a month. No thanks to Aetna.
Then there's the blood tests for the fetus. The cystic fibrosis test was $1008 at Aetna's pricing. This one really took me by surprise. Retail price is $1200 for the test, so for Aetna to charge me $1008 was odd - their prices are usually more like half of the original cost. Especially odd when you compare it to the MaterniT21 test from Sequenom, which at retail is $2762. The Aetna price is $133. I blew through my deductible with the MaterniT21 test, and then Aetna paid for 80% of the remaining cost. (Phew!)
The ugliest thing about all this is that this is the result of 'managed care.' Managed care means more expense for the patient. These were all tests that I needed to have. They weren't optional tests. They didn't come with a steak and baked potato. Aetna wants me to pay through the nose to stay alive, essentially. If I hadn't gotten the blood tests that revealed my blood clotting disorder, I would have miscarried. Even worse, it would have endangered my life. My blood clot in 2010 developed into a pulmonary embolism. The final straw was a bill I received on Monday, for an ultrasound that Aetna decided they wouldn't pay for. It's because I received another ultrasound on that same day. They paid for the cheaper one, and now I have another $472 to cough up for a medical procedure.
Two priorities should be:
• Specialty drug price reform.
PhRMA President John Castellani called on HHS to limit insurers’ ability to structure drug coverage in a way that subjects patients with these types of chronic and severe illnesses from these type of high out-of-pocket costs. “Placing all medicines in the highest cost-sharing tier makes the best treatments for patient outcomes and overall value the most expensive and undermines the goal of the ACA. Cost to the patient is determined by the insurance market,” Castellani said during the event.
• Cost control of medical
tests.
Whether directly from their wallets or through insurance policies, Americans pay more for almost every interaction with the medical system. They are typically prescribed more expensive procedures and tests than people in other countries, no matter if those nations operate a private or national health system. A list of drug, scan and procedure prices compiled by the International Federation of Health Plans, a global network of health insurers, found that the United States came out the most costly in all 21 categories — and often by a huge margin.
If you want Texans to get to the polls in November, health care cost reform needs to be on the agenda. I'm barely keeping my nose above water, and it's because of careful negotiating with providers, begging for financial assistance, and online coupons for medications. Not to mention the medications I've done without. At this point I need to go on WIC so that I'm getting enough nutrition for my pregnancy. I can't afford fresh vegetables and fruit. I shudder to think of how things will be next year, with a kid to take care of!
This isn't a pity party. This is a call to action.