No wonder Medicare is going broke

They might have billed Medicare for $11,000, but they will likely get only a pretty small fraction of that.

The financial hole that's been dug with Social Security is a drop in the bucket compared to the massive burden imposed upon the taxpayers with Medicare/Medicaid. As the population ages and as more indigent refugees continue to pour across the border into the country - it'll only get worse. Running a $1.7 trillion or more as I type with a $33t plus government debtload. The interest paid on that debt alone is running close to $700b a year. If my parents (and many in their generation) didn't have the cash to pay for a large expenditure (vacation, car, new TV, home remodel, etc...) it just didn't get done. Now everybody just pulls out the plastic and presto, manna from heaven. Well, enjoy it while you can.

I have Medicare Advantage. No reason for me to pay an extra $225 a month for a decent supplemental. My Advantage plan gives me whatever I need and more. $0 co-pays for most everything and only a $1000 max out of pocket. Very happy with all my docs. All emergencies during foreign and domestic travel covered. Plus, my Plan rebates me for about half of my monthly Part B SS charges. I guess it all depends on where you live. In my area the consumer is king when it comes to Advantage plans.

TJ - If you have a free plan and get money back, you don't have to look far for reasons why Medicare is going broke Medicare is limiting out-of-pocket drug cost over the next two years and my drug premium dropped from $7.50/mo to $0.50/mo for next year. Explain that shell game to me?

Medicare is basically a funding problem with a bunch of political problems surrounding it. The boomer surge has been known for years and it has never been dealt with, period. It is exactly like the school issues that followed the boomers when school crowding was common, many new schools were built, then schools get closed and enrollment drops at the remaining schools, repeat. A vicious cycle that happens over and over again for those who don't understand history.

You will get little argument about the sorry state of the national debt from most boomers (ie: me).

Post Edited (Mumbo) : 11/16/2023 1:26:55 PM (GMT-8)

I am on the generic not the original and they are billing 11k to Medicare. You can buy it for $125 on good RX

Mumbo. It’s more than that. Pharma lines the pockets of politicians who then vote against legislation that would lower the cost of prescriptions. Pharma is allowed to charge Medicare what ever they want to charge for medications sometimes to the tune of thousands of extra dollars thereby making Medicare unsustainable. It’s ridiculous. Everybody is getting rich and then bit&@I g about entitlements when they have the power to fix the problem.

Not being argumentative, but what is billed and what actually gets paid are often two different things. Basically, Medicare does not pay for drugs under Part D as it is set up for commercial insurance companies to make the reimbursement. There can be some Medicare subsidies at the catastrophic level from Medicare, but all that is very clearly spelled out in your Medicare Advantage plan with United. With Medicare Advantage, the pharmacy will bill the commercial insurance company, United Healthcare, for reimbursement. If there is a Medicare subsidy it would be handled between United and Medicare. Your cost would be any deductible and copay, which you indicated that you paid $100.

Again, you should be able to use the GoodRx coupon to buy the drugs if it is better than your United copay. Just ask your pharmacist, and choose the best method. As an example, my wife takes ezetimibe, the generic for Zetia the anti-cholesterol drug. Through our pharmacy and Plan D company WellCare our cost for 90 days is $132.00. By using the GoodRx discount card we paid $24.79. It was an easy choice to make. In your case it looked like your United copay was less than the GoodRx so that was the right decision for you.

You should have received the 2024 drug formulary from United so you should be able to see what your costs are going forward and determine the best method to meet those costs. And actually, Medicare significantly controls drug and service reimbursements. As an example, when we went on Medicare, my wife was receiving a monthly hormone shot for breast cancer that the oncologist billed at $10,000 and our insurance reimbursed the doctor $7,500. When we went on Medicare, the reimbursement dropped to $2,500. The oncologist still billed $10,000 per shot but, of course, did not get what they billed and received just 1/3 of what they had been receiving. Just how it works.

It’s a Ponzi Scheme Jack . The inflated amount billed is how the pockets get lined.

Artificially high Medical billing is a fact of life brought upon us by negotiated prices by thousands of third party payors, these being commercial insurance companies, labor unions, government like the VA, Medicare, Medicaid, self insured companies, cooperatives, associations, HMOs, etc.; and the thousands of providers. Everyone that understands this dynamic thinks nothing of it, while those not part of it set their hair on fire with every bill. The huge bills and relatively small amounts of actual reimbursement is just the way of the system.

Each provider like a hospital, doctor, pharmacy or drug company must start the negotiations with all of these payors by setting a price for a service higher than any will be negotiated because they can not negotiate higher than what they first establish, and this is the amount they must bill. They then do the negotiations with the payors and numerous agreements are made at vastly different amounts for a lot of different reasons like geography, population of a payor’s patients, networks, competing providers and payors, etc.

As a member of a payor group, we go to a provider having no idea what the charge or negotiated reimbursement will be, but we do know what our out of pocket expense will be based on deductible, copay, and network status. What happens next should be of no concern to the patient as it is purely between the provider and payor. But then we get an outrageous bill…..and then an Explanation of Benefits that shows the bill, reductions and adjustments due to the reimbursement agreement or Medicare limits and then the reimbursement amount actually paid and finally any amount the patient is liable for through deductible, copay and network status. Often the reimbursement is as little as one tenth the bill. Makes no sense. Right?

A year ago I had an incident that landed me in the emergency room for several hours and an overnight stay in total of about 18 hours. I had no real treatment or surgery and was not administered any drugs other than the ones I take per daily prescriptions. I did have several assessments by three different specialists, a CT, MRI and Echocardiagram. I was discharged with minimal followup and one change to a prescription. Several weeks later I get a non-itemized bill for over $33,000. No surprise or worry as the bill was absolutely meaningless. A month later I got the Medicare statement and the EOB from my insurance company. In all there were about $2,500 of reimbursements made to all the providers and I paid a $50.00 emergency room copay. I consistently say the bill doesn’t matter and no one pays the bill. Don’t rage about the bill. The artificial overcharge amount is not expected to be paid and is basically a bug of the system. What matters is the EOB and the portion the patient is responsible for.

JNF - This takes me back to the days of List Price and MSRP and the reasons for such things such as anti-trust, wage and price controls, etc. The “price” can be manipulated to mean almost anything and rarely reflects selling price except where a manufacturer has such market control to hold pricing (Apple and Bose come to mind).

The issue with proprietary cancer drugs and similar products is tough as many times the alternates are terrible. I have been in a proprietary business and everyone loves the product and hates the company since they don’t give the it away, just a fact of life.

Todd1963 said...
I know that this post may be walking a thin line but this is a valid topic. It is not about party… Take sides of the aisle out of the equation.

Yeah, you guys are creating a lot of work for me, I actually have to read every post no matter how long LOLOL.

On another note, before Cialis went generic, and for a couple of months afterwards, I was having to pay close to $300 for a 3 month supply, AND go thru the gyrations of getting pre-approved. Then I found GoodRx, and started paying between $12 and $25 dollars. It shows how broken the system actually is.

Prato - Information is key and the drug people do everything in their power to keep pharmacies from doing anything to help customers unless they ask. The common procedure is the doctor electronicall sends the prescription to pharmacy who fills it and bills based on the insurance on file, no questions asked. The consumer goes to the pharmacy, pays the bill, and rushes home to take the new med. What could be wrong with this system?

JNF - A flip side of this is that mutual funds and pension funds invest in the drug companies and everyone is happy when their retirement and pension plans are doing well. Everything is a Catch-22.

TJ - this link should help explain my concern.
https://www.npr.org/sections/health-shots/2021/11/11/1054281885/medicare-advantage-overcharges-exploding
This will get sorted out someday.