Helping make the health care system work for you

Impatient reader's dogged persistence wins Anthem drug approval

pills money medicine

Photo by Chris Potter via Flickr Creative Commons

David Garden will now pay $75 for a 90-day supply of Cymbalta.

Here's a happy tale of persistence rewarded. When I spoke to Impatient reader David Garden last month, he was getting samples of Cymbalta from his doctor, and carefully cutting them in half. He was threatening to fill his prescription of the drug – commonly prescribed for depression - through an illegal supplier in Canada.

It was all because he'd switched Anthem Blue Cross plans. He went from an employer-sponsored plan to one purchased on the Covered California exchange. He later learned that the new plan did not include Cymbalta, or its generic version, on its drug formulary.

Garden has a form of muscular dystrophy, and he takes the drug to alleviate the chronic neuropathic pain associated with his disease. Suddenly, a 90-day supply of the drug increased from a $25 co-pay to $512.77.

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How to decode your health insurer's Explanation of Benefits

Employees pay directly for their health insurance in "defined contribution" plans.

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Reading an explanation of benefits, or EOB, can be very confusing.

As loyal Impatient readers know, we're a month into #PriceCheck, a collaboration with KQED and ClearHealthCosts.com. Through this project, we're building a robust database of certain health care prices in California. We started by crowd-sourcing the cost of mammograms, and now we're focusing on all types of back MRI's.

We've invited you to participate in the project. To do this, you need to enter a couple pieces of information from your explanation of benefits, or EOB: The charged price, what insurance paid, and what you paid.

Widespread confusion

We know that navigating your EOB is not easy; in fact, it can be downright frustrating.  (Side note: That's just another reason why we're so thankful to everyone who has participated in the project so far!)

That frustration bubbled up last night during a Twitter chat focused on health costs transparency, co-hosted by our partner ClearHealthCosts.com.

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Next up for #PriceCheck: Back MRI's

MRI

Paula Steele/Flickr Creative Commons

The PriceCheck project is collecting the costs of all kinds of back MRI’s: lower back, upper back, with contrast, and without contrast.

In June, we launched PriceCheck, in collaboration with KQED and ClearHealthCosts.com.

In the first month of the project, we crowd-sourced the cost of mammograms. We asked our audience members to grab their medical bill or Explanation of Benefits, visit PriceCheck, and enter three bits of information: The total price charged, how much their insurance company paid, and how much they paid.

Mammograms: $60 or $649?

Our community provided us with valuable information. One of our contributors – Annie Brown, of Toluca Lake – told us her insurance company, Anthem Blue Cross, paid $649 for her mammogram at Glendale Adventist Medical Center.

That compares with $60 for a mammogram at the H. Claude Hudson Comprehensive Health Center. (That’s a self-pay price, and the lowest one in our database.)

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More voice frustration with Anthem and other insurers

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PhotoDu.de/Flickr Creative Commons

Anthem says it stands ready to help members who need help with issues regarding their health insurance.

Last week, KPCC reported that Consumer Watch had filed a class action lawsuit accusing Anthem Blue Cross of fraud and unfair business practices "allegedly intended to lure customers into buying its health insurance plans."

I asked Impatient readers if they’d ever felt misled by Anthem Blue Cross, or another insurance company. A number of people responded on this blog and on the KPCC Facebook page, telling us about their frustration, confusion, and annoyance regarding their insurance companies.

"I don't know if the word 'mistreated' is quite strong enough," Rachel Yonda wrote on Facebook.

Yonda said she switched to Anthem at the beginning of the year because of a "'bait and switch' situation" with Blue Shield. After moving to an Anthem EPO plan, "we are continually surprised by what isn't covered, and finding an unexpected amount of fairly routine care is subject to our deductible (so not being covered at all for the time being)," she wrote.

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As screening recommendations change, should we re-name the annual exam?

Even if you're under 25, you should still know your blood pressure, a study says.

Rudyanto Wijaya/iStockphoto

One doctor emphasizes that annual visits are more than just a pelvic exam and paper smear. Women's height, weight and blood pressure can also be measured at these visits.

Recently, we told you about the American College of Physicians' new recommendation against pelvic exams for healthy women who are not pregnant and show no symptoms of disease. The advice follows other recommendations in recent years that altered the traditional well-woman exam landscape.

Other exams

In 2009, the U.S. Preventive Services Task Force recommended that women should start regular breast cancer screening at 50, instead of the traditional 40. It also said women should undergo the screening every two years, instead of every year. The CDC says women ages 40 to 49 should talk to their doctors about when to start getting mammograms.

In 2012, the task force recommended that women between 21 and 65 should undergo cervical cancer screening, or a Pap smear, every three years. It recommended that women between 30 and 65 who don't want to have the screening that often could receive a Pap smear and HPV test every five years. Other groups – including the American College of Obstetricians and Gynecologists and the American Cancer Society – also recommend against annual screening.

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