
Insurance copays are higher than the cost of the drug about 25% of the time - jabo
https://www.pbs.org/newshour/health/why-a-patient-paid-a-285-copay-for-a-40-drug
======
drawkbox
Health pricing is a weird fixed pricing with all sides in insurance companies,
medical suppliers and doctors holding the cards to get the highest prices
within the gamed rules with the consumer left out in the cold and each bill a
random output that is rarely known beforehand.

Part of the problem is healthcare provided through work that skews pricing for
large companies over individuals/small/medium businesses and entrepreneurs.

If we can't get healthcare removed from employers and have both a private and
public option based on Medicare for all. We AT LEAST need legislation to bring
in CLEAR pricing for insurance cost and non-insurance rates, similar to the
CFPB mortgage Loan Estimate and Closing Disclosure that show all pricing
clearly in one sheet of paper both the estimate and the final mortgage.

What other product do we buy that the price is not known until after the
product/service is rendered? At least some idea of an estimate is even hard to
get as each part of the medical pricing matrix scam (insurance companies,
medical services/suppliers, doctors, pharmaceuticals) try to keep pricing
shrouded to stick it to people wherever they can.

The consumer healthcare experience is horrible in the US healthcare system and
employers being the insurance companies main customers is a major part of this
problem but pricing can be helped with clear regulations and needs to be now.

~~~
analog31
In my view, understanding the flow of money in the health care system will be
impossible until the system is wholly owned by the government. This may be the
primary reason why health care in most civilized countries costs half of what
it does here. Until then, everybody who's gouging us accuses everybody else of
being the ones who are gouging us.

~~~
conanbatt
The most frustrating issue with the Bernie Sanders single payer campaign is
that they flat out lie saying that the reason why healthcare is expensive is
because it is private.

Healthcare hasnt been so expensive forever, it was actually very cheap decades
ago, when it was still private. The efficiency issues are not public vs
private. Its mostly regulatory burdens.

~~~
scarface74
Yes regulatory burdens like actually being forced to cover people with pre-
existing conditions, not being able to drop people once they use thier
insurance and not being able to exclude certain conditions....

~~~
conanbatt
More like burdens like limiting the amount of doctors available, not allowing
the importation of foreign drugs, tying healthcare to the employer, etc.

You can manage the problem of pre-existing conditions in an insurance system
with a subsidy, instead of a mandate that forces a 20 year old minimum wage
person to work part time, because the employer cannot afford to pay healthcare
for him.

~~~
scarface74
_More like burdens like limiting the amount of doctors available,_

There has never been a law in the US limiting the number of doctors available.

 _tying healthcare to the employer, etc._

There was never a law tying healthcare to the employer. Before the ACA, if you
had a preexisting condition, that was the only way that you could get
insurance - by being part of a covered group. The insurance company wouldn’t
cover you.

 _You can manage the problem of pre-existing conditions in an insurance system
with a subsidy, instead of a mandate that forces a 20 year old minimum wage
person to work part time, because the employer cannot afford to pay healthcare
for him._

So we need universal coverage like the rest of the civilized world....

~~~
conanbatt
> There has never been a law in the US limiting the number of doctors
> available.

There is at least one such limits to about 1/4 of 65.000. And even within that
limit they have an irrational amount of extra requirements.

> There was never a law tying healthcare to the employer.

Sorry but in the US, health insurance is provided by the employer because it
is a tax-exempt expenditure. Tax it and see wages diminish considerably once
employers pass the cost to the employees.

> So we need universal coverage like the rest of the civilized world....

The uncivilized world also has universal coverage. That should be a red flag,
shouldn't it?

~~~
scarface74
_Sorry but in the US, health insurance is provided by the employer because it
is a tax-exempt expenditure. Tax it and see wages diminish considerably once
employers pass the cost to the employees._

Employers already pass the cost to employees through lower wages.

 _The uncivilized world also has universal coverage. That should be a red
flag, shouldn 't it? reply_

Yes, that in this regard the US is worst than a third world country...

~~~
conanbatt
They don’t pass to the employee the marginal tax rate pf the health benefit,
which by the way is a very regressive policy.

And you would be very wrong to believe healthcare in the us is worse than in
third world socialized medicine countries. You will find horror stories galore
as well as all other kinds of trade offs you wouldn’t accept.

------
cascom
I had this experience with imaging (MRI), cost 10% more with insurance than
without.

I asked a friend in the healthcare industry about this - they said that since
insurance companies negotiate all the services at once - the insurance company
is trying to lower the total cost for the whole insured pool, this often means
that they will marginally overpay for high margin services in order to get big
discounts for the really costly things. The hospital makes more gross margin,
and the insurance company lowers it’s total spend. The offshoot is that
individual people may bear the brunt of this grand bargain...

No idea if it’s true, but had a ring of truth to it...

~~~
antjanus
I had the same situation with multiple services:

1\. ultrasound cost around $300 with insurance...$150 without

2\. ER visit cost $4K with insurance....$900 without

3\. specialist visit with insurance cost around $200...$150 without

And don't get me started on labs.

It's really a rip off to use insurance for anything other than:

1\. general doctor visit (cheap co-pay, pretty expensive cash option)

2\. really expensive shit (c-section w/o insurance runs $25-$30K -- cost me
around $5K with insurance)

Anything in between seems to be cheaper when you pay individually.

As a disclaimer this is "gold-level" insurance coverage which costs around
$1200-$1300/month for a family of 4.

~~~
sandworm101
Wow. I used to live in the US but thank you for the reminder. I am very glad i
now work a government job in a country with public health care. I went to the
dentist last week. Walking out without paying anything, not a single form,
feels like stealing. I cannot understand how anyone in the US can pay such
costs. Simply staying alive seems a constant battle.

~~~
maroonblazer
What dental services were performed? In the U.S. I frequently pay nothing nor
fill out any forms for dental work.

~~~
sandworm101
Xrays, replaced a filling and got a night guard thing made. Took a couple
hours.

~~~
maroonblazer
Yeah, I've paid nothing for x-rays and fillings. Haven't needed a night guard
yet.

I suspect that the chicanery in the U.S. is more severe in the non-dental
sectors of healthcare as there's more volume/value there (from a
provider/stakeholder POV).

~~~
pfranz
My wife missed a checkup (perhaps two) due to pregnancy. When she went back
she needed a root canal. I happened to need a filling for the first time in 12
years. Before any of my work we had hit our insurance max for the year and had
to pay cash for the excess--about $1000. This all happened in the same month
or two so we didn't know until after.

------
markvdb
Healthcare and profit don't go together. This is just exhibit n°
31415926535897932384626433.

What happens in the software world when you see twentyseven useless levels of
abstraction? Exactly the same. You smell a rat.

In my ideal world:

* Healthcare research funding to come from the public sector and donations only.[0]

* Healthcare products can only be sold once the production process is verifiably fully publicly documented. This means independent reproduction by multiple reputable non-profits.

* Market based generics manufacturers handle production. Competitors (for profit or non-profit) jump in if pricing gets out of hand.

* Healthcare education free to students.

* Only non-profit healthcare services allowed.

* Compensation for people providing healthcare services is linked to median income.

[0] This is not such a big difference as one would think, as more than half of
the basic research in the field is actually publicly funded already.

~~~
arethuza
"Only non-profit healthcare services allowed."

Not sure if this is required - the UK manages to have a socialist health care
system (the NHS) for the vast majority and a relatively small private
healthcare system for those who want treatments not covered by the NHS, or a
nicer room etc.

I'm not sure I'd be happy with completely banning access to private healthcare
- although I'd prefer it if the NHS was resourced to a level where there
really wasn't much need to to go private (which certainly used to be the
case).

~~~
Khaine
I wouldn't hold the NHS up as a paragon of virtue. I got sick on a recent trip
to London and tried to get in to see a GP under the NHS and it was impossible.

The clinics near my hotel only accepted same day bookings. I tried calling
just after opening hours and the phone was engaged. I managed to get through
15 minutes after the clinic opened and the clinic was booked out for the day
and I would have to call back the next day. I tried a number of clinics and
they were all booked out. I was lucky that I wasn't that sick and got better.
Otherwise, I was looking at an exorbitant fee to see a private doctor.

I was shocked, as I always assumed that the NHS was better than the system we
have in Australia. I think that there are lots of perverse incentives involved
in Medicine and Healthcare. Government intervention is required to balance out
these incentives from profit takers and consumers (i.e. smokers, obesity,
etc). I'm not sure that any model in the world right now gets the balance
right.

~~~
arethuza
Note my comment about "I'd prefer it if the NHS was resourced to a level"....

The issue with not getting GP appointments quickly seems to have been a
relatively recent thing - due to lack of resources and mismanagement rather
than fundamental problems with the approach.

~~~
Ntrails
That's not entirely true. If you're actually emergent and require a same day
apptmnt then they've got held appointments for you. However this has led to an
extremely strange system where often GP receptionists are essentially
gatekeeping services (as a pre requisite to accessing the GPs who gatekeep the
other services...)

------
jwr
Something is very wrong with the whole medical insurance system in the US.
Having recently been exposed to it, I keep discovering new surprises and being
shocked regularly.

What I found most bizarre is that Americans who are "temporarily" in the US
(e.g. expats, visiting) can get health insurance with better terms and at
about 1/10th the price of what residents are offered.

Someone is being had, I'd say.

~~~
MrMorden
That could be because for the really expensive stuff they'll pay for you to be
transported back to your home country, where your primary insurance will treat
you.

~~~
jwr
No, that is not the type of insurance I was writing about. To take an example,
take a look at Patriot America Plus from
[https://www.visitorscoverage.com/visitor-health-
insurance/pl...](https://www.visitorscoverage.com/visitor-health-
insurance/plans/)

It does include the acute onset of pre-existing conditions, $250 total yearly
deductible, 100% percent in-network coverage. But it is not available to US
residents, only for short term (up to two years) stays.

~~~
kalleboo
> _The Patriot America Plus Plan is available for any_ non-US Resident _,
> visiting the USA for a short period of time_

> _Pre-existing conditions are not covered by Patriot America Plus Plan_

It requires you to already have insurance somewhere else, and they expect you
to go home for anything chronic (expensive). It sounds exactly the same as any
travel insurance you can get in your home country (and is included in many
fancy credit cards)

You said "expats" before, but ex-pat implies residency in the US.
Tourists/business travelers are a whole other ballgame. They're just
protecting against not getting hit by a car when they're at their week-long
conference. They're all limited in scope of their costs by their visitor's
visa duration (typically 90 days)

------
tialaramex
Under the NHS most patients pay a "prescription charge" which is intended to
encourage patients not to seek prescription meds when they needn't do
anything. (Several big categories like pregnant women are exempt from charges,
and if you use lots of medicine you can "prepay" a fixed fee of about £100
each year to stop getting charged regardless)

The charge is more than some cheap OTC medicine you might get prescribed, e.g.
hay fever tablets are pennies per box and the charge is almost £10. But
pharmacists are required to tell you if you could just buy it yourself for
less - they collect the charge so they have the opportunity to point this out
whereas your doctor needn't know if you pay or not.

Logically the charge must also be bigger than the price for some of the
cheapest prescription-only medicine and there's no way to avoid paying extra
in the UK as far as I know in this case.

~~~
jdietrich
Over 90% of prescriptions are free, because they're prescribed to exempt
groups (children, the elderly, people on benefits). It's a slightly peculiar
system that doesn't make a huge amount of sense.

[https://www.pharmaceutical-journal.com/news-and-
analysis/pre...](https://www.pharmaceutical-journal.com/news-and-
analysis/prescription-charge-overhaul-would-raise-1bn-a-year-for-nhs-says-
think-tank/20066348.article)

~~~
pdpi
The alternative conclusion is that it’s fulfilling its purpose as a deterrent
against abusing prescription medication

------
crivabene
I am on the same exact medication. I live in Italy. My 90-day supply is 15
euro (5 euro per box), but the government covers most of it through the
healthcare system, so I end up paying 3 euro (1 euro per box).

~~~
dev_dull
And you could probably get it even _cheaper_ if you ordered them from a
pharmacy in India.

~~~
jarfil
Except they'd probably get stopped by customs.

~~~
walshemj
and might be counterfeit

~~~
HarryHirsch
Anyone who thinks the FDA should be abolished should read the Warning Letter
of the Week and reconsider:
[http://chemjobber.blogspot.com/search/label/warning%20letter...](http://chemjobber.blogspot.com/search/label/warning%20letter%20of%20the%20week)

~~~
reaperducer
_Our investigator documented that you have an employee food preparation area
within your drug manufacturing area with no separation between open
manufacturing equipment, cooking utensils, and personal-use items. The
practices observed at your facility, which was observed open to the outdoors,
increase the likelihood of your drug products becoming contaminated._

~~~
HarryHirsch
Eating in the lab is poor form, it goes against all the social norms a
manufacturing chemist has imbibed during their training. Such poor discipline
usually points to further trouble, and indeed there are deeper problems:

 _You provided no evidence that you have performed chemical and microbial
testing on each batch you manufactured before making a batch disposition
decision._

------
brd
I have a doctor friend who's made it a habit to recommend that patients use
GoodRx anytime they go to pick up prescriptions. Doctors can only be so
involved in the pharmacy side of the transaction and a lot of pharmacists
aren't able to intervene.

It's sad that it requires a 3rd party app to help people not get screwed over
by the current US medical system.

~~~
ramphastidae
Are you aware of any privacy issues with GoodRx? I’ve avoided it because I
assume they are making money selling my prescription information.

~~~
reaperducer
I can't say if GoodRx is doing it, but Walgreen's seems to be selling
information.

I was with a friend picking up his meds and I bleeped my rewards card to
collect the points, since he didn't have one. Now I get offers in the mail to
treat his condition.

~~~
jetti
So this has been a roller coaster. My initial thought was that this was a big
HIPAA violation but then I decided to actually look to see if my assumption
held up. According to the Department of Health & Human Services page on HIPAA
and marketing [0], Walgreens can use personal health information (PHI) in
marketing without violating HIPAA, as long as they have permission to do so.

So with that in mind, I went and looked at Walgreen's notice of privacy
practices [1] and they say that they will get a written disclosure before
using PHI (and that is restated in their Balance Reward ToS.

Bottom line is, if they are selling information then hopefully you're friend
has signed a form authorizing use of the PHI otherwise Walgreens is violating
HIPAA.

[0] [https://www.hhs.gov/hipaa/for-
professionals/privacy/guidance...](https://www.hhs.gov/hipaa/for-
professionals/privacy/guidance/marketing/index.html)

[1]
[https://www.walgreens.com/topic/help/general/noticeprivacypr...](https://www.walgreens.com/topic/help/general/noticeprivacypractices.jsp?foot=privacy)

------
arenaninja
I do wonder if insurance paying for everything under the sun is part of the
issue. I remember hearing talk of medicine for some chronic conditions being
available over the counter (migraines, diabetes, asthma, etc.). The way I see
it, my car insurance only covers a limited number of issues. Unfortunately,
health insurance has historically come on the wrong side of things (e.g.: pre-
existing conditions BS)

~~~
lotsofpulp
Health insurance in the US isn’t insurance. It’s a scheme to try and spread
around the costs of providing healthcare to everyone, and everyone tries to
pass the buck to those with the least power in the system. Large employers
with young, healthy office workers win, and poorer taxpayers who don’t have
health insurance or independent contractors who have very little power lose.
The people who have nothing get medical care, but it’s not ideal, but they
don’t have anything to pay with either.

So try not to be in the middle - the ones with enough assets to take, but not
enough to defend against having them taken (e.g. not being part of a group
that can negotiate out of it).

God forbid we actually come out and say we, as a country, want to support each
other. A large portion of our fellow citizens would rather play this game of
hot potato, but don’t have the balls to turn poor people away from the
emergency room and tell them to die.

~~~
scarface74
_Health insurance in the US isn’t insurance. It’s a scheme to try and spread
around the costs of providing healthcare to everyone_

That by definition is insurance....
[https://www.investopedia.com/terms/i/insurance.asp](https://www.investopedia.com/terms/i/insurance.asp)

~~~
lotsofpulp
The key difference is that the recipients are also others who pay for
insurance, whereas in US health insurance, it’s a game of see which provider
can collect more from which payer (government, insurance, individual) to make
up for the losses on those that can’t pay.

Also, chronic and old age health issues don’t even seem like insurable risks,
like getting 20 year term life insurance for a 90 year old. You would
basically just be paying for someone else to manage your premium money and
take a cut before giving it back to you since the insured risk is inevitable
and has to be priced accordingly.

~~~
scarface74
_The key difference is that the recipients are also others who pay for
insurance, whereas in US health insurance, it’s a game of see which provider
can collect more from which payer (government, insurance, individual) to make
up for the losses on those that can’t pay._

Health costs between what you pay as an individual and what you pay as part of
a group is just like anything else. You couldn’t buy the same parts for a
computer at the same price as Dell. Dell can get bulk discounts you can’t.

A health care provider is willing to charge less for care per person for a
group of people through an insurance carrier than you individually.

If you have ever signed up for term life insurance, you usually get a fixed
premium up to a certain age, and then premiums skyrocket as you get older. You
theoretically can price life insurance for a 90 year old based on actuarial
data. The cost will be prohibitively expensive.

~~~
lotsofpulp
An individual isn't paying increased costs for parts for computer because the
merchant was forced to sell parts to someone for free. A merchant might be
making less on the marginal profit to a large vendor (or accept slight loss to
benefit from the marketing of having a large customer), but I don't see it
quite as bad for the little guy as it is in US healthcare.

Edit: I understand the analogy of a bigger buyer means better prices, but it's
a little different too because the merchant of the computer parts can't bill
the losses to the government who then pays via increased taxes. The pricing
differences are astronomical too between what prices are given to people who
want to pay cash versus via insurance or Medicare or Medicaid, it makes no
sense.

I see the US healthcare market as the middle and lower middle class spending a
larger portion of their wealth subsidizing the poor class while the upper
middle and upper class spend a smaller portion of their wealth subsidizing the
poor class because they can negotiate out of it, and they probably get better
care too.

And this is all exacerbated because employers get to deduct health insurance
premiums from taxes, while independent contractors buying insurance
independently don't.

~~~
scarface74
Health insurance is deductible as an independent consultant.

[https://turbotax.intuit.com/tax-tips/home-
ownership/deductin...](https://turbotax.intuit.com/tax-tips/home-
ownership/deducting-health-insurance-premiums-if-youre-self-
employed/L6bRhLaVE)

~~~
lotsofpulp
Is that a recent change? I was under the impression that people who buy their
own insurance can’t deduct it, or at least I haven’t ready any 1040
instructions that say you can. What if you’re employer doesn’t offer health
insurance and you buy it? Then you’re not an independent contractor, but you
still don’t get it from employer.

~~~
scarface74
It’s part of your standard business expenses as an independent contractor.
It’s been that way at least since 2012 when I was a consultant.

~~~
lotsofpulp
Interesting, thanks for the correct info. I can't seem to find anything about
people employed by small business that aren't required to offer health
insurance, so I think they still have to purchase health insurance themselves
with post tax income, so I guess my point only stands for them.

But still, it's all needlessly complicated and unreasonable to expect people
to be able to optimize in our current system.

~~~
scarface74
If you are employee and receive a W2, you can only deduct healthcare expenses
that are more than 10% of you income.

I would say that any company, no matter how small has no excuse not to offer
health insurance to thier employees. The cost in administration is minimal and
can be outsourced. I have a relative who runs a law firm with just herself and
one or two assistants and even she offers unsubsiduzed health insurance. I’m
not saying they should _subsidize_ the cost. Just by offering it through the
company, it’s cheaper for the employee because the company can offer it
pretax.

As an employee, I would never be an _employee_ of a company that didn’t offer
insurance if I needed it. If they won’t offer (unsubsidized) insurance, and I
want to work for the company, I would insist on working as an independent
contractor at a rate that would make up for not getting paid time off, self
employment taxes, and future unemployment benefits.

------
ohazi
What would happen if we suddenly made opaque pricing illegal? If anyone sells
anything to anyone, they'd be required to publicly disclose the price.

Having thought about it for all of thirty seconds, I can't see any downsides.
Can anyone convince me otherwise?

~~~
therealdrag0
Not necessarily a downside, but in some industries I think most people don't
care that much if different customers get different prices.

Like B2B, often the sales people feel out and negotiate a customer to see how
high they can sell a product/service for. And that can actually be nice for
small companies. They are probably getting subsidized by larger companies to
some extent. I know the company I work for has negotiated very aggressively on
some of our infrastructure pieces (metrics, config-management, db etc), where
there was no way we could afford the sticker price.

EDIT: OTOH making opaque prices illegal, wouldn't bar negotiation.

------
doctorless
Do pharmacists have to take the Hippocratic Oath? How is not telling your
customers that the insurance copay is higher than cash not harmful?

~~~
alphabettsy
There are articles such as this:
[https://www.pharmacytimes.com/contributor/douglas-
jennings-p...](https://www.pharmacytimes.com/contributor/douglas-jennings-
pharmd-fccp-faha/2016/06/when-should-patients-pay-cash-for-prescriptions) ,
suggesting that some contracts forbid pharmacies from mentioning a cash option
to patients. Which should be illegal.

------
dev_dull
Another example of how distorted prices are in this market. Price discovery is
nearly impossible. Some places can't even tell you how much a drug cost
without insurance because _they don 't even know!_

~~~
howard941
Anecdata warning . Took paper Rx to a very large chain that has a one word
name beginning with a W and was told they wouldn't quote the cost of the
prescription without scanning the Rx. And destroying it so I couldn't take it
anywhere else.

~~~
freedomben
Often times they take the script and put their sticker on it before even
checking if it's in stock. I have had this happen numerous times. I then go to
another pharmacy because the first was out of stock (and my time is worth
nothing, so of course I can drive all over town and stand in line for 20 to 40
minutes at each place) and get interrogated by the pharmacy tech, "did you
take this somewhere else to fill!!???" Because apparently only a criminal
would fill a controlled substance. And with the DEA artificially limiting
production, it's _very normal_ for the first three pharmacies to be completely
out of stock.

------
dv_dt
I am skeptical of claims that the US heathcare system could be fixed solely by
better consumer medical information. But this is one area where consumers can
often save money - just by asking their pharmicist when they go to fill a
prescription to run the cost both under insurance vs cash pay.

One wonders what value health system administrators are providing when such a
high percentage of negotiated drug plans result in higher prices than cash
prices.

~~~
wallace_f
>One wonders what value health insurance administrators are providing

Good question. This was also discussed last week on HN[1].

Since 1970, the number of doctors is up 150%, in line with pop. growth, while
healthcare administrators up by 3200%.

1-[https://news.ycombinator.com/item?id=17756845](https://news.ycombinator.com/item?id=17756845)

------
alex_hitchins
Can someone explin to me how the US prescription process works? As someone in
the UK it seems quite alien.

~~~
zifnab06
It's always seemed weird to me as well. Let's say you go to the doctor for
something like strep throat. You get a prescription for an antibiotic. Doctors
offices don't carry drugs, so you take this prescription to a pharmacy to fill
it. The pharmacy is a third party that isn't affiliated with the doctor's
office. Only doctors can write prescriptions, and as far as I'm aware only
pharmacists can fill them. Pharmacists aren't allowed to write prescriptions,
even if it's something trivial.

On the insurance side, it's a nightmare. The doctor probably charges your
insurance $200 for the office visit. Your insurance has a negotiated rate with
the doctor's office for $150. You have a coinsurance of 50% if you've met your
deductible, so assuming you haven't hit your max out of pocket for the year
you pay $75. If you haven't met your deductible (some arbitrary amount you
have to pay on top of paying for insurance) you pay $150. If you have hit this
max out of pocket number, you'd pay 0. The $50 goes into the void. My
employers insurance is something like a $1000 deductible / $5000 max out of
pocket / 75% coinsurance.

When you get the prescription filled, well, I have no idea how this insane
process works. Last time I needed antibiotics the receipt had a "before
insurance" amount of $50 with an actual cost to me of $4. I have no idea where
the $46 went or what my insurance actually paid.

~~~
alex_hitchins
In the UK, I go to a doctor, get the prescription. Some doctors in rural areas
have pharmacies joined on but I think the majority don't. I go to the
pharmacy, hand in my prescription and pay £8.80 per item (so two boxes of the
same drug is £8.80). I pay upfront, so it costs me £104 a year for anything
prescribed by an NHS doctor.

I see US folks talk about getting half their prescription filled, or seemingly
using the same prescription multiple times. We can submit repeat prescriptions
(such as I do for BP etc). but the actual prescription 'document' is a one
time deal.

It's very, very odd to me the way it's set up over there. Especially so that
some people fight so hard against change.

~~~
jsmith45
For chronic medications it is common to have a single prescription include
multiple refills. So one paper document might get you 4 months worth of
medication, but only filled 1 month at a time.

Mail order pharmacies often fill 90 days at a time, possibly with multiple
refills. 90 days dispensed at once is uncommon at retail pharmacies, but is
possible in at least some cases. (Not sure if it is laws or contracts that
normally prevent this).

It is also possible that a pharmacy may not have enough to fill the script all
at once, so they dispense only part, and you come back for the rest later.
(I've never experienced this so I'm unclear on the details.)

------
csomar
Not from the US. But how in God sake does this make any possible sense? I mean
if the insurance doesn't want to insure a certain medication, then you just
pay it for yourself (provided they explain why; or that your contract said
so).

But how could it be possible that you pay more?

~~~
reaperducer
_you just pay it for yourself_

That used to be the way it worked. You'd go to the doctor and he'd charge you,
say, $35 for a basic exam, and you'd pay in cash.

Since health insurance became widespread, now doctors charge crazy amounts. My
doctor charges something like $210 for a basic exam, or $185 for the
"negotiated rate" to the insurance company.

I saw on television once that the reason we're in this mess has to do with
WWII. With so many working-age people fighting overseas, finding workers was
hard for companies, so they started raising wages. The government was afraid
of war + inflation, so it put limits on pay raises. So, instead, big companies
started offering health care benefits. And thus, an industry was born.

At least that's what I remember from the TV. I can't cite the show or channel,
but I do watch a lot of PBS and virtually zero YouTube.

~~~
scarface74
_Since health insurance became widespread, now doctors charge crazy amounts.
My doctor charges something like $210 for a basic exam, or $185 for the
"negotiated rate" to the insurance company._

The price a doctor charges per hour doesn’t go directly in his pocket. That
hourly cost has to cover support staff, the facilities, liability insurance,
his accountant, etc.

~~~
reaperducer
So did the $35.

------
Spooky23
I think the telmisartan story is cherry picked to tell the story the author
wanted to tell.

I’m on that drug, and have a good health plan that charges the lesser of copay
or actual cost for drugs.

That drug was going generic two years ago, and it took the generic
manufactures awhile to ramp up. The generic drug cost more than the name brand
version for a few months and was constrained — the pharmacies my my area had
difficulty doing a 90 day fill.

It ultimately didn’t drop to super cheap status until they were approved to
sell it in a normal pill bottle — previously it was sold in blister pack form.

------
samstave
Watch "drug Short" on the "Dirty Money" series on Netflix. It pretty enraging,
and you are likely already familiar with the story, Valeant Pharma and Martin
Skrelli....

[https://www.netflix.com/watch/80149535?trackId=14170289&tctx...](https://www.netflix.com/watch/80149535?trackId=14170289&tctx=0%2C2%2Ca534ce77-e4b4-4d8c-9077-4da1a44b8a0e-77260350%2C331d9787-d92a-4dfc-b506-3eb056dd1503_30039662X3XX1534727957227%2C331d9787-d92a-4dfc-b506-3eb056dd1503_ROOT)

------
aceon48
I wonder what % of people now believe the US medical system is the scam that
it is. Utterly dishonest pricing.

------
nobrains
I live in Dubai. I used to get glasses made for AED 100 - AED 200 (USD 27 to
USD 54) when I was young, based on what I remember from visits to the
opticians with my dad. No insurance.

Sometime after that insurance was introduced. Now, as an adult I pay AED 100 -
AED 200 (USD 27 - USD 54) [basically the same amount] as 20% co-insurance when
getting glasses.

Note 1: USD and AED are pegged.

Note 2: There has been inflation, but not that much. Tea increased from AED 1
to AED 1.5. Taxi increased from AED 10 to AED 20. Clothes increased 50%
perhaps.

~~~
skate22
Slightly off topic, but you can order glasses (frames and lenses) for under
$10 on zennioptical.com

Ive ordered my last 3 pairs there, and will never pay $200 for glasses again

------
dawhizkid
Not sure how widely known or common this is for medications but I take PrEP
(Truvada) and the maker has a free "co-pay" card on their website that
basically covers $4800/year in copayments (well above the $50/month I would
ever pay).

I'm sure there's some shady big pharma economics behind why these exist in the
first place, but at the very least I'm getting a very expensive drug for free.

~~~
bradleyjg
> I'm sure there's some shady big pharma economics behind why these exist in
> the first place

The co-pay is designed to make you share in the pain of the sky-high costs the
drug manufacturer charges the insurance company. This has two benefits—1) you
are only going to get it if you really need it 2) maybe you’ll lobby your
congressperson to rein in monopolist pricing.

By giving you a coupon there’s no pain sharing and those benefits are lost.
Sure you’ll pay higher premiums, either directly or in reduced wage gains, but
that’s defuse and indirect, so far less likely to drive behavior.

~~~
zdragnar
Biologic drugs are grown, not manufactured. Mine should be around 4k / dose;
insurance won't cover it, so the drug company only charges me I think a $25
copay.

Fwiw, the insurance would have covered older alternatives, but the potential
side effects on those are worse than the cure.

~~~
bradleyjg
Should be in what sense? Is that the marginal cost to manufacturer a dose?

~~~
zdragnar
Should be in the sense that I don't recall the specific number, only that it
was around $4k. Given the decreased consistency in the process (living things
vs. mixing chemicals), I imagine a fairly good chunk of that 4k is also
marginal cost to the manufacturer. Everything from research, to scaling up
production, to storage and shipping (spoils at room temp) becomes more
expensive.

------
ghaff
I'm not sure I understand this article. I take a few drugs the cost of which
is less than the co-pay and I pay that lesser amount when I pick up my
prescription from a major US pharmacy chain. They have my health insurance
info and would charge the co-pay if the amount were more. But they don't
because the retail price is less.

~~~
sitkack
I have routinely had to pay the $20 minimum for generics that cost $5 retail.
So I paid $15 over retail for using my health insurance.

------
linsomniac
My experience is that it's more like 90% of the time. My "lessons learned" is:
Talk to your pharmacist and see what options they have for cash payment and
discount cards like GoodRx. It takes them a couple minutes to compare to your
insurance, but for me it's cutting the cost of my prescriptions by around
half.

My insurance has a $10 copay, but limits me to getting 30 day supplies.
Currently they are moving to require you to get refills through them by mail,
which would be fine except I'm skeptical that it would cost me significantly
more.

I have 3 prescriptions, which with the monthly copay would add up to $90 a
quarter. Using the "GoodRx" or other "discount card", those 3 prescriptions
with a 90 day supply end up costing me around $40 a quarter.

The meds for my family's recent set of illnesses were cheaper with the GoodRx
than the copay, but just barely.

------
stevetodd
Prices vary also a ton from pharmacy to pharmacy. I recently discovered GoodRx
([https://goodrx.com/](https://goodrx.com/)), which has been extremely helpful
in minimizing prescription costs.

* Not affiliated.

------
refurb
Maybe this is a dumb idea, but why not change the laws so medical insurance is
more like car insurance - the insurance company works for me?

If I get into an accident and it’s the other drivers fault, my insurance goes
after them for the money.

Would be interesting if once a physician decides to perform services for you,
he/she is bound by the insurance you have. If they don’t like it, then they
work it out with the insurance company, not you. As a patient, you’d know up
front what your responsibility is.

Would sure as hell speed things up in terms of physicians and insurance
companies figuring shit out.

~~~
turc1656
_" Would be interesting if once a physician decides to perform services for
you, he/she is bound by the insurance you have."_

That's not how the car insurance model works. You have an agreement with your
insurance company to provide a certain amount of coverage, irrespective of
what has actually happened. If, for example, there is $2,500 of damage, and
insurance covers $2,000 of it, the mechanic isn't stuck eating $500. You get
billed for that, and rightly so. The mechanic is specifically (and legally)
bound to offer the same service/repair at the same price. The mechanic cannot
quote you differently for a repair based on the insurance you have and is not
bound to any agreement with your insurance company. The mechanic merely
accepts the remittance made by the insurance company on your behalf as being
towards the total repair cost.

------
pasbesoin
I wonder how much we'd save if we just (say, "economically", for the sake of
"civil" speech) whacked all the middlemen.

It's like going to the grocery store and wondering how much this "Monopoly"
game (just came up in conversation with the clerk at the checkout lane, this
evening) is really costing you.

Bunch of "marketing" gurus in suits. On top of the "prizes", I'm paying for
them and their suit.

Bah

------
maxxxxx
It's just mindboggling that pricing in medical is so opaque. Mandating
transparent pricing should be the number one reform everybody should be able
to agree with.

~~~
HarryHirsch
_Mandating transparent pricing should be the number one reform_

In normal countries patients manage to do without shopping around suppliers
altogether, but in the US that very fact is unimaginable to many. People
outsource all sorts of things, Gusto is a YC company that companies use to do
payroll, but Americans cannot imagine that the civilized world has outsourced
prescription medicine pricing to the government and that it gets a good deal.

~~~
drblast
Americans can imagine that just fine; it's just harder to imagine _our_
government handling this in a beneficial way.

~~~
AnIdiotOnTheNet
Our government is a reflection of us, if we demanded a better system we'd get
it, the problem is that we hate other Americans and want to hurt them far more
than we want to help ourselves.

~~~
dang
Could you please stop posting unsubstantive and/or snarky comments to Hacker
News?

[https://news.ycombinator.com/newsguidelines.html](https://news.ycombinator.com/newsguidelines.html)

------
mamon
...and the other 75% of the time pharmaceutical companies simply factor in the
insurance payments into the drug price raising it to unreasonable level.

------
panda888888
I have so much experience with this, as do thousands of women.

Before the ACA was enacted, insurers were allowed to charge copays for birth
control pills. I was paying $50/month ($600/year) for something that cost
literally pennies for them to manufacture.

Generic birth control pills are one of the most common, cheapest medicines out
there. I'm glad that the ACA outlawed copays for them.

~~~
swebs
>I was paying $50/month ($600/year) for something that cost literally pennies
for them to manufacture.

This applies to the vast majority of drugs. Most of the cost either goes to
recouping R&D or funding less profitable drugs.

~~~
panda888888
True. My point is that the most common drugs are often the cheapest, so this
25% number quoted in the article isn't a surprise at all. I actually would
have guessed that it would be higher.

------
crb002
Save some by paying out of pocket? You can still use it as a healthcare
expense come tax time.

~~~
briandear
Health expenses only matter if they exceed 7.5% of your income for a given
year. Using flex accounts though, that would give you a big tax win. Flex and
HSAs are really the only way to really get tax savings on health since the
standard deduction was doubled in the Trump tax plan.

------
ars
Want to do something about it?

[https://www.gormanhealthgroup.com/blog/trump-
administration-...](https://www.gormanhealthgroup.com/blog/trump-
administration-alarms-pbms-with-first-drug-pricing-initiative/)

Take action and write, tell them you oppose the PBM's and want drug kickbacks
removed from the safe harbor exception!

This is what you are up against: [https://www.pcmanet.org/wp-
content/uploads/2018/07/PCMA-comm...](https://www.pcmanet.org/wp-
content/uploads/2018/07/PCMA-comments-on-Blueprint-RFI-July-16-2018.pdf)

Oh, they sound very convincing with great charts and data and bullet points.
But they are very very wrong, they are looking out ONLY for themself!

I can't find where to comment, and I think the comment period might be closed,
but doesn't matter write anyway. Encourage the Trump administration to do it
and get rid of kickbacks!

------
h4b4n3r0
Yep. I take blood pressure medication. Cost without insurance: $5.70/mo. Cost
with insurance: $10 co/pay. I know this because my insurance lapsed once for a
month. Same exact pills, same manufacturer even.

------
aviv
I have many friends and family members that frequently complain about the high
cost of their health care and insurance premiums. Yet most of them are leading
unhealthy lifestyles, a mix of bad diets, smoking, sedentary lifestyle, etc.
There seems to be a big disconnect in their head between how they live their
lives and how much it affects their health spending.

Sure, it would be nice if pharmaceutical drugs cost less, and if copays were
cheaper. But it would be much better to not need either of those to begin
with.

