Medical costs – preexisting conditions and letting patients help

My S4PM colleagues Jeanne Pinder with the Clear Health Costs project and Casey Quinlan with #howmuchisthat for healthcare keep us updated on the popular topic of healthcare costs.

This inspired me to look into my own healthcare costs. I have good private insurance covered by my employer. Still my employer is forced to pay higher and higher premiums all the time and one day we will all have to do our best to reduce those costs.

I have ulcerative colitis. If Obamacare wasn’t around I could not get individual insurance if I needed it in the future. This is one of those preexisting conditions that make me uninsurable. Why? Let’s see my costs for two years 2011 when I was in remission and did not incur many costs related to my chronic condition and 2012 when I had a mild flare in terms of what can happen to ulcerative colitis patients. I did not land in the hospital and all I needed was some extra medication and a colonoscopy. I put the raw data in this file.

  • The costs for the uneventful year 2011 for me were $15 vs. $839 in 2012. Fair enough, I had a major procedure – colonoscopy that has a $500 copay and I needed medication with a few copays.
  • My insurance plan covered almost $700 in 2011 and about $6500 in 2012.
  • It gets interesting when you look at what the hospital/physicians claimed from the insurance plan: $4025 in 2011 and over $20,000 in 2012. This is what I would have to pay if I had no insurance – for basic care in 2011 and a mild flare in 2012.

Two costs jump out as outrageous: in 2011 my hospital charged us $2532 for basic tests (CBC, lipid profile, etc.). My insurance paid $176. This is almost 15 times higher price that I would have to pay if I was uninsured… Definitely gives me pause and makes me think twice about going to that particular hospital even though I love my doctor very much. They also charge a “facility fee” for each visit. Fortunately my insurance doesn’t pay that.

The second cost is the colonoscopy costs. First it is made out of four costs: actual colonoscopy, pathology, anesthesiologist and gastroenterologist. The anesthesiologist was paid more than my doctor or the pathologist that read the biopsy result.

I am an e-patient, so I care about costs. I am supposed to do a colonoscopy every year. I was willing to try to see how it feels without anesthesia. I asked my doctor and she said we’ll play it by the ear… There are other places where you are given options:

There are multiple sedation options – nothing at all, versed/fentanyl, and propofol/monitored anesthesia

I was not given options and I did not want to ruffle any feathers – you do not want the team to be surprised and make up a new protocol specifically to deal with you… (I can ruffle feathers now, after the procedure is done)

My hospital is trying to get as much money as they can by gauging the costs and making the most expensive option the default. It is a non-profit, but they are building a new wing and they are advertising the cyberknife.

My insurance company is actually quite good in how it negotiates good prices and is transparent and allows me to see all the information.

But wouldn’t we all be better off by working together? Doesn’t the hospital realize that the price gouging is pushing me away? Can the insurance company help me to reduce costs by requiring that I am given a sedation option?  Could we get better prices for my medication (it is  brand medicine and there is no generic available)?

Would we all be better off if I worked with a dietetician – I am doing my best to figure out what triggered the flare and avoid getting one again. Doctors usually say that flares come and go at random without reason, but it was my experience and a lot of other patient’s experience that we can influence a lot by avoiding certain foods. We know what makes it worse for us…

I think there’s a lot to gain if we all worked together. And I think I as a patient could help a lot if I was helped to understand options, costs and learn from other patient’s experience.


About Ileana Balcu

Passionate about healthcare, participatory medicine, e-patients, databases, IT and Health IT, social media, communication, teams and yoga. Proudly volunteering for the Society for Participatory Medicine #s4pm

Posted on February 24, 2013, in Uncategorized. Bookmark the permalink. Leave a comment.

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