Posted 3/19/2015 7:13 PM (GMT 0)
about a year ago, the hospital system my GI doc is affiliated with decided to take infusion appointments out of their doctors offices and transfer them all to a central clinic. The clinic was not at the hospital, but somehow, because they labeled it the "hospital infusion clinic", they were now able to bill insurance the same as if I had been getting my Remicade while laying in a hospital room as an in-patient. My infusion bill went from around $6500 every 8 weeks to a little over $20,000 every 8 weeks. Almost the entire inflated part of the cost was attributed to the drug suddenly costing much, much more.
Despite patients calling the hospital to question this move and complain about the ridiculous price increase, despite their GI doctors and the leaders of the hospital clinic itself complaining to hospital administration, despite the moral problems of fleecing chronically ill patients who rely on these medications to maintain a decent quality of life (kind of a problem, since this is supposed to be a "Catholic hospital"), the hospital administration decided they had made the right choice. Every time I had a conversation with the people at the hospital where my calls were routed (the lower-level billing/information people whose job it apparently is to get me to stop asking questions and not give me any opportunity to contact the actual decision-makers....little did they know I had ways around them!), they wanted to know at the beginning of every conversation, "Well, how much did your out-of-pocket go up?"
It was a chore to explain that my out-of-pocket was not the point. The point was that because of their arbitrary price increase, I was now going to incur more medication expenses per year than we spent on our house when we bought it 16 years ago. The point was that my husband's company is self-insured up to a certain amount, so it's not a nameless, faceless company that is bearing the cost of this medication, it's the very company we depend on for our livelihood. The point is that although I have fantastic insurance, if I allow myself to be billed outrageous amounts, I only participate in perpetuating medical costs that get more & more out-of-hand every year.
It took a year and working with a patient advocate nurse at my insurance company, but we recently came up with an alternative to the hospital infusion clinic. She knew that the mail-order pharmacy that fills our prescription orders has a specialty pharmacy associated with it. The specialty pharmacy supplies all sorts of medications you wouldn't necessarily associate with a mail-order program. Best of all, the pharmacy contracts home care nurses who will come to your house and run your infusions if that's the sort of delivery method your medication requires.
In my situation (not sure if this is always the way it works for every company), the medication will be run through my pharmacy coverage rather than my medical coverage. My "specialty" co-pay is around $150, and because the pharmacy cooperates with the RemiStart program, RemiStart should pick up all by $5 of that cost. Best of all, the pharmacy bills the drug at less than $3000 per infusion, and there is no charge for the nurse. So each year, this method will save around $130,000 a year over what the hospital would bill us.
Home infusion probably isn't for everyone. In my case, I've been using the medication for over a year and never had any problems at all with the infusions. The pharmacy ships epi pens and benadryl along with your first batch of medication, just so the nurse has an "emergency kit" on hand, and she could slow a reaction while you were transferred to the er (just like they would do at any infusion clinic). The only hassle I can think of is that you have to store the infusion pump & pole at your home (it un-assembles and you can fit it in a big rubbermaid tub.) Other than that, it's the same (or better) as having to go to the hospital clinic.
I know that the high cost of meds is a concern for a lot of people, and this was a very "hidden" option to me, so I wanted to get the word out that you may have alternatives to expensive hospital clinics. If your insurance has nurses who check in with people who have chronic illnesses to manage and people who incur high medical expenses, they can probably tell you if this is an option in your system. The regular customer service people at my insurance company were completely unaware of this option because I called a couple times early on asking if there was anywhere else I could go to be infused with Remicade other than the hospital clinic. Alternatively, if you know you have a mail-order pharmacy company (the sort of place that will send you 90 days of oral medications at a time), you could call them and as if they are partnered with a specialty pharmacy. My guess is that they would be able to answer that question and get you in contact with the right people from that specialty pharmacy.
Remember, we may depend on hospitals and medications to keep our illness in check, but that doesn't mean we don't have any power. If your hospital is taking advantage of patients by charging fees that are outrageously un-competitive just because they think you won't bother to fire them, consider your alternatives. And if you decide to go elsewhere, make sure to let your old clinic know exactly why you left. It's better business for them to take the long picture with chronically ill patients - mine could have kept billing me $6500 indefinitely and made a lot of money off of me, but I wouldn't have left because $6500 is competitive for Remicade in the US. But because they jacked up their prices so high, they had me for less than 1 year and now another business will be paid for possibly many years to come, as long as Remicade keeps working for me.