The other day an acquaintance of mine, a woman who lives in Philadelphia's western suburbs, made her regular quarterly visit to the endocrinologist. She has Type 2 diabetes and, for the past 15 years, has used an insulin pump as an important part of managing her condition.
She turned 65 this year and began coverage under Medicare, along with a private Medicare Supplement policy. As many people know, Medicare prescription coverage is afflicted with the onerous "Donut Hole." That means after spending $3,300 out of pocket for prescriptions during 2016 (the amount changes every year), she is responsible for paying 42-45 percent of her subsequent drug costs until reaching a total of $4,850. After that, she is on the hook for just 5 percent of additional costs for the rest of the year.
Someone with diabetes might fall into the Donut Hole during the first or second quarter of the year, even if she controls her condition quite nicely and is otherwise healthy. That is because standard treatment for diabetes often includes two or three medications: one or two for blood sugar, a statin to keep cholesterol low, and an antihypertensive to manage blood pressure.
Although Medicare is the closest this country comes to the rest of the developed world in making health care affordable, it is not without its own costly afflictions. In this case the culprit was Farxiga, a brand of SGLT-2 inhibitor and one of three medications that my acquaintance, an educational administrator, uses for her diabetes.
Before this year, when her coverage came from a group plan at work, she paid nothing for her Farxiga. That was because the drug's manufacturer, AstraZeneca, provided her with a co-pay card that covered her entire out-of-pocket cost on the drug. AstraZeneca still received 80 percent of its negotiated price from her employer's group carrier, Independence Blue Cross.
Unfortunately, relief from the Farxiga co-pay cost ended this year when she started on Medicare. That is because Medicare legislation has made it illegal for manufacturers to provide the system's beneficiaries with co-pay cards. The reasoning behind that prohibition is sound, although it punishes Medicare recipients. Co-pay cards eliminate the outrage from millions of Medicare beneficiaries, but by insulating consumers from pharma's annual price hikes, they make it easier for the companies to profit off the government (as they do off of private insurers, who of course pass the cost on to their subscribers).
If that weren't bad enough, the cost for the insulin that my friend also requires has more than doubled during the past five years. The costs of various supplies she needs for her insulin pump have risen as well.
But she is resourceful and determined to fight against a health care system in which pharma companies, distributors, hospital networks and private insurers all pursue profits to the detriment of American consumers and taxpayers.
So, during the week before her latest endocrinology appointment, she spoke to several pharmacists (including one in Canada), an eldercare social worker, a disability attorney and a variety of what she calls "connivers and schemers" on internet chat sites.
From these sources she learned that Medicare would pay for her insulin and pump supplies if her endocrinologist writes the prescription with some specific language. Then, instead of getting her 5 mg Farxiga pills from the mail order division of the pharmacy benefits manager that supports her Medicare prescription insurance, she was able to buy 90 days worth of 10 mg pills from a Canadian walk-in pharmacy at one-third the price. They shipped the medication to her, together with a free pill splitter that turned it into a six-month supply. (This is perfectly legal, although not sanctioned by the Food and Drug Administration.)
When she visited her endocrinologist she was eager to tell him about the money saving suggestions she had uncovered.
The physician maintains the largest diabetes practice in his county – almost 30,000 active patient files. He seems to be a highly capable, supportive doctor who is eager to help his patients with all aspects of managing their diabetes. Yet when this patient told him what she had learned about saving some out-of-pocket costs, he said he had not heard of those tactics.
She is relieved that she will be able to manage her drug costs for the rest of this year. She knows, however, that the rules and the loopholes keep changing every year, that pharma companies relentlessly keep increasing prices, while insurers and employers try to pass more of the added costs onto beneficiaries and workers every year.
"I know that every spring," she said, "underwriters at every insurance company sit around in Louisville or Minneapolis or wherever they meet and look for the particular kind of usage patterns that are driving up their costs. Then what they'll do is change the benefit pattern and increase the premiums."
The result is that stratagems and ploys that work one year may be useless the next.
The message is this: Even making a part-time job out of trying to game the health care system can be a losing proposition. The odds are stacked heavily in the house's favor and, in this case, drug companies and insurers are the house. Columns that offer tips to consumers about saving money on their medications may not help much, either.
Things will stay this way until people accept that fact that in health care, the culture of individual consumerism doesn't apply. Unlike groceries and clothing, the concept of wise health care shopping is almost a contradiction in terms. A smart fellow named Benjamin Franklin once said, "We must hang together or hang separately." In this case, his words jump off the page.