In this week’s JAMA Network Open, Kapadia et al analyzed Medicaid claims to assess who was more or less likely to receive Hep-C anti-viral treatments. These treatments are remarkably effective. The current standard of care is that individuals should be on these drugs as soon as they are diagnosed with Hep-C. That is not the case:
Of the included patients, 43 078 (49%) were females, 12 355 (14%) were age 18 to 29 years, 35 181 (40%) were age 30 to 49 years, 51 282 (46%) were non-Hispanic White, and 48 840 (49%) had an IDU diagnosis. Additionally, 17 927 patients (20%) received HCV treatment within 6 months of their HCV diagnosis. Patients who initiated HCV treatment were more likely to be older, male, and less likely to have IDU [my emphasis added]
The time frame that the researchers looked at was 2017 through 2019. This is after the OH MY GOD THESE DRUGS ARE HYPER EXPENSIVE shock when Solvaldi came on the market at the price of the starting annual base salary for an assistant professor in health policy at a mid tier school. By the time the study period started, there were multiple Hep-C drugs on the market, rebates were massive and there were authorized generics in the pipeline. These drugs aren’t cheap even after their net price got knocked down massively, but they are extremely cost-effective over a several year time horizon.
Access to care is likely a function of social power. The authors examined the factors that were associated with the odds of receiving Hep-C treatments. They found that people who checked the boxes of older, male, white and urban were more likely to get guideline concordant care than others. Power likely matters.
Insurance helps, but it is not sufficient to get care that people need.
RaflW
Your headline is true for lots of people on conventional work-based insurance, too. High or even medium deductibles are of course a hurdle.
A friend has breast cancer. She was diagnosed right around the time of an orderly job change. No gap in coverage, but she and her family will have to meet two large annual deductibles this year.
So even under ACA, and with my friend earning a very respectable middle class salary, they’ve had to turn to a Go Fund Me. It’s freakin’ enraging how bad our care-pay-system is in the US.
Ohio Mom
You also have to be an informed, squeaky wheel of a patient. If you don’t advocate for yourself, all bets are off. Ask me how I know.
Of course, this set of attributes usually goes along with older, male, white, and urban. I check three of those four boxes.
Butch
@RaflW: Yeah, we just got a bill for $1,600 for services the insurance company had assured us were fully covered. Talking to the insurance company was futile and the folks at the state insurance commission consider it their job to answer the phone and tell you there’s nothing they can do.
But on the other hand, what’s IDU?
Ohio Mom
@RaflW: For your friend: breast cancer.org is the best site I found (see above, being an informed patient). The site has up-to-date information on aspects of breast cancer (founded and edited by doctors), and the discussion boards are very helpful.
I’d rate their commentariat up their with Ballon Juice’s, informed, articulate and caring.
Good luck to your friend!
Ohio Mom
@Butch: A quick look at the linked article, looks like IDU = Injection Drug Use.
I’d guess that being a user who injects is another one of those sociological markers.
Alce_e _ ardillo
File this under the No Shit Sherlock, file for healthcare disparities. Also people with IVDU are less likely to get treatment even though abstinence from opioids is not necessary to be treated.
Yarrow
@RaflW:
A similar thing happened to my cousin. I mentioned it in a previous insurance thread. A pregnancy on first insurance and an unexpected diagnosis just after changing insurances because of job change. It was very expensive for them.
It’s so hard for those families when it happens. It really seems like it could be something fixable with legislation. Something like: the amount you’ve paid in deducible for one insurance company is “portable” to the next one. You somehow get “credit” for what you’ve paid. Maybe limit it to two changes per year or something. Possibly limit the total deductible you can pay in a year.
I understand this affects a small number of people but when it does hit it’s just awful and it usually seems to accompany a difficult diagnosis, so people are already stressed.
David Anderson
@Ohio Mom: A woman who I spent a good chunk of my undergraduate time with, her dissertation was on factors associated with social permission to be strong and very goddamn wrong all the time…. I read those papers several times as the key concepts were floating in her mind as we drank too many bad beers as underage undergrads in a shitty bar in Pittsburgh. She had a goddamn good point about social power.
Yarrow
@Butch:
I once spent three days trying to find out how much a CT scan would cost. The doctor’s office couldn’t tell me. The radiologist organization (it was outsourced to them) couldn’t tell me. The insurance company couldn’t (or wouldn’t) tell me. The insurance representative doing the three way calling with me and the “patient advocate” crap service they offered couldn’t tell me. NO ONE could tell me how much it would cost.
I asked if they could at least ballpark my portion of it. $50? $500? $5,000? $50,000? I had no idea and they couldn’t tell me. In the end I just had to decide to get it or not. Flying blind on cost. It’s little wonder people just walk away thinking, “Maybe it’s not that bad. Maybe it’ll get better.”
Our “health care” (ha ha ha) system is such a mess.
Roger Moore
@Alce_e _ ardillo:
This is a great example of people rationalizing their discrimination. Especially when the treatment was extremely expensive, people felt as if it was necessary to ration it. The basic idea was that IV drug users were a bad group to give the limited supply of medication because they had gotten themselves into their trouble by using drugs and were more likely to be re-infected. Instead, the medication should be given to virtuous people who hadn’t gotten infected through such risky behavior.
What this ignored was the IV drug users were the best target from a public health perspective. They were far more likely to infect others, so each IV drug user they treated would do more to prevent further infections and thus reduce the future case load. By focusing on things like deserving vs. undeserving patients, we wound up adopting a really counterproductive strategy.
RaflW
@Yarrow: That is an interesting area for legislative policy (when we can again have a Congress that does such things. McCarthy seems highly unlikely to be the leader of such a body).
Assuming continuous coverage, yeah, if two sequential policies have an “annual out of pocket cap” of, say $8,000, that should be it for the year. If you change jobs April 1, insurer A gets $2K, and insurer B gets $6K. Oversimplified, but something like that.
It’s obscene that a family has to cough up $16K in a single insurance year, on top of their contributions to premium.
Roger Moore
@Yarrow:
I can’t help but notice how much better Kaiser is on all this stuff. I never have to worry about this kind of cost. I pay an up-front fee when I walk in the door- sometimes that fee is $0, depending on the service- and I don’t have to pay for anything beyond that. They can tell me how much it will cost in advance, and they can make the price stick. It makes a huge difference that everything is under one roof. There’s no case where the doctor’s group doesn’t know how much the radiologist’s group will charge, because they aren’t in separate groups. I think they save enough in overhead to cover the extra costs from not trying as hard to ration services.
Yarrow
@RaflW: Yes, I could see it working like that. It’s prorated somehow, likely based on the months you have each insurance policy.
It’s obscene that people get hit with double deductibles and OOP. It really needs to be fixed in some way.
Sister Golden Bear
Especially when your insurance company denies a prescription you’ve been on for years, saying they need more information, and then make it impossible for your doctors to reach them to provide that information. Even though I’m working, I can’t afford $1,000 out of pocket for it.
JaneE
I was raised like my parents to think that you only went to the doctor when you really needed one. I expect there are still people today who don’t go to the doctor because something is not serious enough to warrant it, even though there are medications today that could really help even with the smaller stuff.
The ACA has not been in effect all that long. Even aside from all the people who could not (and maybe still can’t) afford medical care, there were lots of people that put off care because they did not have insurance, and did not want anything on their medical record that would indicate a pre-existing condition existed. On person who was a friend of a friend did some permanent damage by putting it off until he could afford to buy a policy. That was just a couple of years before the ACA eliminated the need to do that.
Add in the issues that don’t have symptoms or not anything indicating a serious condition, and it is no wonder that having the ability and having the care are very different.
thalarctosMaritimus
@David Anderson:
I’d love to read her work, if you don’t mind providing her name for looking her up. Thanks!
@David Anderson:
Ohio Mom
@David Anderson: I like this: “social permission to be…very goddamn wrong all the time.” That describes so much of what we all have experienced. For one, how many bosses does that describe?
Chris
Relatedly, I just got a bill for $2,000.00 for a series of fairly simple tests that were run last December to try to determine what I was suffering from at the time. Apparently my doctor sent them to people who weren’t in-network, and I didn’t think to verify or specify that at the time. (In my defense, was sick enough at the time that thinking clearly wasn’t at the top of my list).
Having insurance is better than not, especially when the monthly premium is paid for my your employer, but my God, do I still hate this fucking system.
Chris
@Yarrow:
I’ll never forget the time when I was hit with a $7,000.00 bill for a chest scan, similarly because of “turns out this wasn’t in network.” Since I was so close to broke at the time, my lawyer cousins volunteered to contest that bill with the insurance company once they found out about it. Within a matter of days, the balance had dropped to zero (admittedly after I’d already paid a few hundred) and I never heard any more from them.
They can’t tell you because they have no idea what they’re going to charge you for it. Their business model is literally to just throw the highest number they guesstimate they can get away with at you, knowing that since you can only buy the service without knowing the price, you’ll be on the hook for it.
Roger Moore
@Chris:
This. The prices listed for medical services are completely imaginary. They’re what the provider would like to charge, and everything is negotiated from there. If you have a good insurance company, they will have done the negotiation ahead of time, but the provider will try to come up with excuses for weaseling out of their negotiated price.
This was a big deal when I was on a jury for an injury claim. The plaintiff was asking for money to pay for future medical care, and an important part of the case was figuring out how much it was going to cost. The plaintiff had a medical billing expert, and he was only able to provide a very rough estimate. We on the jury were all sure it was an overestimate, but we really had no idea how far off it was. We wound up giving the defendant a bunch of money, but we really had no idea if it was enough or way more than the actual cost.
Mai Naem mobileI
I can’t believe this crap is still happening in 2017. I would like to see a study with another similarly expensive disease treatment but without the IDU issue just to see if that made a difference.
OT I have a friend who had an appendectomy and we were talking about the 20-30 page discharge paperwork package with the ‘core’ discharge instructions on p.8. Do these hospitals really think people are going to read these? Elderly people are going to read it? Somebody’s going to stop smoking(and the papers are there even if you aren’t a smoker) because you put it in a massive discharge packet which will more than end up in some cubby hole? What a waste of time and resources.
Yarrow
@Mai Naem mobileI: OMG, I recently helped an elderly person intake into hospital after being sent there by urgent care. The hospital did the intake on a tablet BY VIDEO. I couldn’t hear it and the woman on the screen spoke good English but with a strong accent, so it was doubly hard to understand and hear. The elderly person couldn’t operate the tablet, which was HEAVY, and couldn’t hear them at all. It was such a mess. The nurses just rolled their eyes. Apparently every patient complains about it. It must “save money.”
They wanted to go through the medication list and they couldn’t even screen share properly. They did something that cut off the sides of the list and it couldn’t be enlarged so no one could read it. A complete clusterf.
WhatsMyNym
@Yarrow:
That’s a good indication that they don’t have an agreement with the insurance company. Time to look elsewhere when you are told that.
CT scans are common and relatively inexpensive. MRI’s are getting that way. I have to at least 2 brain MRI’s a year and they are so busy now at UW (Seattle). I’m told Dr’s routinely use them.
Ohio Mom
@Mai Naem mobileI: I had to get stitches a couple of months ago, ended up in the nearby hospital’s “express” *emergency department.
My discharge packet was only four pages long but the boilerplate contradicted itself in a couple of places. Fortunately, it was only stitches and I could trust the internet’s advice on something so simple.
* I had to laugh at the designation of “express.” It is really an in-house urgent care and nothing about it was fast. The staff was in slow motion. My nurse kept disappearing for fairly long periods.
Now the “real” emergency room, next door, I am sure they can be extremely fast when required.
WhatsMyNym
@WhatsMyNym: I see my insurance company last year (UnitedHealth, Oregon) was only paying $1,600 for my brain MRI; with & without contrast.
Butch
@Yarrow: I no longer see this doctor because of his love for overtesting, but a few years ago he sent me to the local hospital for a test. The medical technicians were standing in a group studying something in a folder. Finally, one of them walked up to me and said “We can’t figure out why the doctor ordered this test for you.” Since then if the physician (or whoever) can’t give me a good reason and a price I don’t do it.
David Anderson
@thalarctosMaritimus: She deserves privacy from me.
Chris T.
@Yarrow:
That’s because there is no single actual price for these things.
Long ago, I had a doctor who wanted to do a CT scan just as I was changing jobs. I called several local CT scan places to try to get prices. One of them was actually able to give me numbers! The cost of the scan with my “old” (outgoing job) insurance would be $X, the cost of the scan with my “new” (incoming job) insurance would be $Y. I forget the exact numbers but the new cost would be higher.
So I scheduled the scan to take place after (yes, after) switching jobs, because the out of pocket cost to me would be roughly $50 lower, while the overall cost would be roughly $20 higher but the new insurance paid a little better for CT scans.
This is not a sane system.
Yarrow
@WhatsMyNym: Well, you’d think so. But the doctor was in network, so I arrived thinking things would be covered. They wanted me to do the scan in their office. I thought it would be covered since he was in network but I asked because I know procedures can be expensive. And that’s when it got crazy.