Archive for December, 2013

Generic Medications — where to get them

genericpillGeneric medications are supposed to be inexpensive!  But, not if you are facing price gouging.  Your favorite chain pharmacy may rip your wallet out and empty it.

The PBS NewsHour reported on 12/23/13 an astounding survey   — they found a generic medication for breast cancer (letrozole) ranged in price from $9 to $400 dollars for a 30 day supply.  Even more surprising the company that charged $400 dollars agreed to match the $9 price at a competitor.

Not only do pharmacies price gouge so do insurance companies.  Almost uniformly insurance drug plans add $20 to every generic prescription.  So a typical $10 generic prescription without insurance involvement will cost you a copay of $30 with insurance.  And, do you think the pharmacist will suggest you avoid using insurance — not usually, since the $20 copay is for them!

What should you do?

  • Shop around — check prices at several pharmacies
  • ASK if there is any program the pharmacy has to lower that price (sometimes if you get a shoppers card you get better prices)
  • You don’t need a membership to get prescriptions from Costco.  Consumer Reports rated them as having the best generic prices.
  • Here is a great place to check prices:  goodrx.com  (and they will print coupons for free!)
  • You can get mail order generics here with free shipping.  Usually their prices are good:  healthwarehouse.com
  • Don’t involve your insurance plan if it costs you more out of pocket than just outright paying for the prescription.
  • Insurance plans often limit the prescription to 30 days (with a copay every time).  Getting your prescription in 90 day amounts saves trips to the pharmacy and often improves the discount.
  • Pharmaceutical companies often make a long-acting medication just before the patent runs out on the short-acting form.  Ask your doctor if the long-acting medication is absolutely needed.  Sometimes taking a medication twice a day at a generic price is much less expensive than once a day at a brand name price.

The price gouging is astounding.  Patients often think a pharmacy just adds a small amount to the wholesale price.  Not so.  They often set the price at some percentage less that the brand name — hugely more profitable for them and devastating for consumers.

The price gouging makes you understand better why the UK and other countries have legislated a solution — they negotiate a country-wide price for each generic medication and allow only a few dollars to be charged as a dispensing fee.  The US has a long way to go to protect consumers and reduce health care costs.

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Dangers for Removing Fibroids – the morcelator

morcelatorJennifer Levits reported in the Wall Street Journal 12/18/13 “Doctors Eye Cancer Risk in Uterine Procedure“.  She recounted the story of Dr. Amy Reed who had a hysterectomy.  The uterus contained fibroids and the fibroids contained cancer.  The procedure was done with an instrument, the morcelator.  In kitchen terms it is a combination blender and vacuum cleaner.  It is used during laproscopic surgery to chop up things (like a uterus with fibroids) and remove them through a small incision in the abdomen.

The problem is the morcelator does not remove all the tissue.  A few cells escape the vacuum and they are left behind in the abdomen.  If those cells contain cancer the cancer is then planted in the abdomen later to grow and likely kill the patient.  Dr. Reed developed the seeding of cancer and claims other procedures would be better.  Traditional surgery removes the uterus and fibroids intact with less chance of spreading any unsuspected cancer.

Here is what the package insert that comes with the morcelator says:

CAUTION: … use of the …  Morcellator may lead to dissemination of malignant tissue.

So what are the statistics?

  • 20% – 40% of women will develop fibroids
  • 1 in 1000 cases of fibroids contain cancer
  • intact removal of fibroids with malignancy failed to stop the malignancy 19% of the time
  • morcelator removal of fibroids with malignancy failed to stop the malignancy 44% of the time

The big question is:  should a morcelator be used if a woman has fibroids because it may double the risk of spreading an unsuspected cancer?

The simple answer is NO, because there are other surgical options.  But, will women accept that answer?  The laprosocopic procedure has less pain and quicker recovery, so the answer turns out not to be so simple.  There are many forces at work on the decision to continue to use the morcelator.   The analysis of these forces is called force-field analysis which was originally described by social scientist Kurt Lewin in the 1940’s.     The following is such an analysis (the rating of force vectors is by the author of this blog):

Morcelator Analysis

So, what will happen?  It seems at this point the morcelator will continue to be used.  But, the risk remains.  Law suits will continue.  Perhaps a safer device will be developed.  Perhaps a high risk of litigation will be perceived by gynecologists and the malpractice insurance companies as  being too great.  Such risk will lower the forces from doctors and perhaps tip the balance.  Time will tell.

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Update (8/1/14):  since the original post the FDA issued a warning about morcelators.  Yesterday, Johnson & Johnson, the major supplier, stopped selling morcelators.  Looks like the forces to abandon the morcelator have been joined by the FDA and the manufacturer.

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Update (2/27/15):  yesterday the Wall Street Journal reported United Health (insurance) requires surgeons to obtain permission for procedures that might use the morcelator — “another blow” to the device.  At this point any surgeon using the device must feel like they are walking a tightrope without a net.

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Legal Loopholes — patient bankruptcy

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Again, Steven Brill of Time Magazine twists the knife in the hospital chargemaster with his article “Bungling the Easy Stuff” published 12/16/13.   Uninsured patients continue to suffer hospital price gouging and personal bankruptcy  even though legislative relief was passed years ago when the Affordable Care Act was enacted.

Mr. Brill explains that the ACA prevents hospitals from collecting fees based on the chargemaster (the discredited fee schedule of astronomic charges).  But, because no rules were published in the Federal Register no legal help is available to victims of the practice.

How could this happen?  Because the work to implement the rules to prevent overcharging did not seem worth the effort, after all, in 2014 everybody will have insurance!  Sadly, during the 4 years up to the time when everybody supposedly will have insurance legal enforcement was sidelined.

Although Mr. Brill piles blame on the Obama administration one must also blame those in congress who pass bill after bill to try to stop the ACA — this is unbelievable — one side not implementing the law and the other side trying to kill the law both without regard to the finances of the vulnerable uninsured while hospitals ignore the will of congress and continue an unethical practice.

Mr. Brill has been hammering on the problems of the chargemaster.  It’s time to listen and help your fellow citizens — hospital boards need to stop the practice immediately.  Citizens need to ask hospital board members why they stand for such a cruel and unethical practice?  Perhaps they should give the money back.  However, the current plan is to use the money to buy ads to extol the caring nature of hospitals — that will make us all feel better.

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