Health Care in the Real World

A lesson for the fuzzy-headed bureaucrats—and for the press

Steve Luxenberg, an associate editor at The Washington Post, gives a different twist on covering high-deductible health plans, that new genre of health insurance that we hope journos—and their editors—will see fit to report on from time to time. Last week Campaign Desk singled out some interesting political reporting on these policies, including a good piece from WBUR, which told of a young man who found that a relatively simple procedure would cost far more than his insurer’s handy-dandy cost calculator had suggested. Luxenberg takes the story of unpleasant surprises even further, suggesting that high-deductible plans aren’t the great health care saviors policymakers have proclaimed them to be.

Luxenberg’s wife has osteoporosis and had been taking a generic version of Fosamax for the bargain basement price of $80 a year. At best, the drug was slowing the loss of bone; at worst, it wasn’t having much effect, Luxenberg wrote. So her doctor recommended Reclast, a newer drug she hoped might be more effective. That’s when the financial fun and games began. Luxenberg has a consumer-directed plan, aka high-deductible insurance, from Aetna. He and his wife had $1500 in their Aetna HealthFund to pay the little stuff. Special savings accounts are often part of these deals. After that, the family had to meet a $4750 deductible or a $3500 deductible per person. Once they do that, then they pay copayments until they reach a $6000 out-of-pocket maximum. Then and only then does Aetna pay all expenses. If the family chose in-network doctors, they would pay less, but they really wouldn’t know what each procedure would cost. “Insurers and providers know precisely what every procedure costs. Only consumers remain in the dark,” Luxenberg reported.

Because the family is on the hook for so much out-of-pocket dough, the price of a new treatment is important. However, they found that price shopping is a figment of the marketplace imagination, not a practical option for choosing medical care. Luxenberg and his wife wanted to know how much more the new drug would cost than the $80 they were spending for generic Fosamax. The quick answer, Luxenberg told his readers, was “no one could tell us.” While everyone they asked—from the doctor’s office to the drug maker’s support network—was nice and willing to help, their answers lacked “clarity.” Sometimes they didn’t know the answer and referred the family to another office. Sometimes what they were told turned out to be incomplete, and occasionally incorrect.

Like Matt S. in the WBUR story, who got a low-ball price from his insurer’s calculator, Luxenberg got one too. He used Aetna’s “Price-a-Drug” online calculator that estimated the price for the drug. Since it was a covered expense, it was expected to cost only $70. Finally, they got some real numbers from an Aetna representative. The price each month would be $1300 plus $300 for the infusion center’s charge. The Washington Post, in its story, says that the drug is given once a year intravenously.*

Weighing the higher price and likely benefits, Luxenberg’s wife said “forget it.” She decided not to take Reclast or generic Fosamax and instead go with calcium, Vitamin D supplements, and weight-bearing exercises for a year and see what happens. Luxenberg concluded: “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.”

The Post’s story is important because it keeps public conversation going on this most important of topics.

*Update: This post originally reported that an Aetna representative said that the new drug would cost $1600 per month. In fact, it costs $1600 per year. CJR regrets the error.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman. Tags: , , , , ,