With the ongoing debate on ways to reform health care, I’ve been thinking about the routine medical care I receive in a typical year. However, living with multiple sclerosis and rheumatoid arthritis, it is not always easy to know if a particular year is going to be “typical” or not. So I examined exactly what health care services I used in one calendar year. Here is what I found:
I saw the rheumatologist three times during the year since I have routine visits scheduled every four months.
Total charge: $433 - insurance adjustment: $202 = $231
Insurance paid: $176
My copayments: $75
I saw the neurologist (or nurse practitioner) five times during the year. In addition to routine visits scheduled every three to four months, I had two extra visits related to a multiple sclerosis relapse.
Total charge: $1,269 - insurance adjustment: $780 = $489
Insurance paid: $354
My copayments: $125
I saw my primary care physician four times, which included one well care visit, two acute illness visits, and one medication visit.
Total charge: $860 - insurance adjustment: $435 = $425
Insurance paid: $325
My copayments: $100
I experienced a multiple sclerosis relapse and underwent five days of IV Solumedrol treatment. This involves going to the Infusion center daily for IV treatment.
Total charge: $3,234 - insurance adjustment: $2,656 = $578
Insurance paid: $463
My copayments: $115
Since I had the MS relapse, I also underwent an MRI of the brain and c-spine. Some MS patients do this annually, but I don’t have MRIs conducted that frequently. Only when indicated by disease activity.
Total charge: $6,017 - insurance adjustment: $1,003 = $5,014
Insurance paid: $4,513
My copayments: $501
Since I turned 40, I also had a mammogram. Squish.
Total charge: $286 - insurance adjustment: $71 = $215
Insurance paid: $215
My copayments: $0
I have routine blood work completed every two months to check liver functions since I take methotrexate for RA. I also had a few non-routine tests related to urinary tract infections.
Total charge: $2,425 - insurance adjustment: $2,066 = $359
Insurance paid: $327
My copayments: $32
I began physical therapy in December and continued twice weekly sessions through March. This was probably the very best treatment for my MS, general health and well being. I’m very lucky that insurance pays for it.
Total charge: $4,821 - insurance adjustment: $1,231 = $3,590
Insurance paid: $3,211
My copayments: $379
I had some visits with a counselor to address mental health issues. I used to go weekly, but now only when I feel the need.
Total charge: $945 - insurance adjustment: $493 = $452
Insurance paid: $226
My copayments: $226
I had the yearly routine visit to the eye doctor and ordered a year’s worth of contacts.
Total charge: $691
Insurance paid: $0
My payment: $691
I also had routine cleaning visits with the dentist and had a special mouth guard made, an unusual expense but highly worth it.
Total charge: $756
Insurance paid: $0
My payment: $756
Thus far, total charges: ($21,737 - insurance adjustment: $8,927) = $12,81nsurance paid: $9,81y copayments: $2,999
I should mention that the insurance coverage I have is through an individual health insurance policy obtained as a self-employed person. I do not have access to group coverage. Currently, my monthly premiums are $329 for this policy which was underwritten, making it slightly cheaper. The major drawback is that the prescription coverage is capped at $1500 each year, an amount which doesn’t go far with you have RA and MS.
Next to consider would be medications. If I were to fill ALL of my routine maintenance prescriptions, the annual cost to insurance would be $33,676. However, with the insurance coverage capped at $1,500 I would be left with a bill for $32,176. There is no way in h*ll I could ever pay that amount.
I use Copaxone which is an injectable medication to treat MS. The price varies by pharmacy but the amount used by the assistance program to determine eligibility is $2,300 per month. Fortunately, I qualify to receive Copaxone through this program at a nominal shipping cost of $15 per 3-month supply and no cost for the drug. The only catch is that I must keep my income below 200% federal poverty level which is $21,660 for a single individual. When I remove $27,600 for the cost of Copaxone from the annual bill referenced above, the new annual cost for routine medications would be $6,076 which still exceeds the $1,500 limited coverage I get from insurance.
The next most expensive drug on my list is Provigil which comes in at $3,992 for a year’s supply, if taken one pill daily. I can’t afford this so I go without or use drug samples obtained at the neurologist’s office. Subtract Provigil from my list and the annual cost for routine medications becomes $2,084.
Now $2,084 is within reach, especially since my copays and deductible would total $660 if I used the mail-order pharmacy approved by my insurance company. The amount my insurance company would pay is $1,424 which leaves me with $76 of coverage for unexpected illnesses which might emerge during the year. Not much leeway.
So what I do is use RxOutreach.com to fill as many of the generic medications as possible (five medications) to save my insurance coverage for the unexpected and brand-name drugs. Doing this allows me to regain $912 of insurance coverage for other needs and leaves the annual amount billed to insurance at $1,172. Subtract $260 for my copay share for the two remaining meds and the coverage available for the unexpected is now $912.
The unexpected did occur last month when I had an MS relapse. When on high doses of steroids, it becomes terribly difficult to sleep so my neurologist prescribed a sleep aid. Ambien doesn’t work for me and I didn’t know that the prescribed medication was rather expensive. I just learned that the cost to my insurance was $390 which now leaves me with $522 of remaining coverage, unclaimed, for the remainder of the year available for the unexpected. I better stay healthy!
To summarize the costs associated with medication:
Total cost for maintenance medications: $33,676
Subtract cost of medications not taken or received through assistance: $31,592
Cost of the seven medications filled: $2084
My out-of-pocket cost: $740
Unexpected prescriptions: unknown cost
So the complete annual price tag on routine health care for me: $55,413
Subtract the amount adjusted by insurance or not obtained through insurance: $40,519
Total amount approved through insurance: $14,894
Insurance pays: $11,895
My out-of-pocket expense: $3,739
Insurance premiums (underwritten) for one year: $3,948
Total annual expense paid by me for routine care and insurance: $7,687
Total expense paid by my insurance company: $11,895
Total expense paid by NORD for my Copaxone: $27,600
So I’m curious…what is the cost of your health care? How often do you see the doctor? Do you have any limitations dictated by your insurance coverage? Are you pleased with your access to health care? What changes would you like to see take place in health reform efforts?
Lisa Emrich is a patient advocate, accomplished speaker, author of the award-winning blog Brass and Ivory: Life with MS and RA, and founder of the Carnival of MS Bloggers. Lisa uses her experience to educate patients, raise disease awareness, encourage self-advocacy, and support patient-centered research. Lisa frequently works with non-profit organizations and has brought the patient voice to health care conferences and meetings worldwide. Follow Lisa on Facebook, Twitter, and Pinterest.