Inside the Little Plastic Castle

On 8 July, I got a cortisone shot in my middle finger, in hopes of warding off surgery for yet another trigger finger. The PT handed me an oval-8 splint to wear that would help the synovial sheath swelling to calm down.

In the mail today, I got a notice from my pharmacy benefit manager (PBM) one of four profit-making entities that I buy health care from. This EOB notice comprised six sheets of office paper, mailed flat in a 9"x12" catalog envelope with a custom window. On top was the single-sided cover sheet with my and their addresses (to fit the window) as well as a boxed definition of "explanation of benefits" (EOB).[note 1] Next was another single-sided sheet with that actual explanation (details below). Then there are four more pages printed both sides explaining how to appeal (in type too small for me to read). These six sheets were mailed unfolded in a catalog envelope from Connecticut (although Navitus is headquartered here in Madison). For personal mailings, six sheets folded in an envelope costs $0.74 — sending flat sheets increases the cost 230%. Commercial postage is less but too confusing for me to calculate.

In the end, the EOB informed me that I might need to pay $1.20 for the oval-8 splint — more than it cost to send me the notice.

I know that many, perhaps most EOBs document important (nay, oppressive) amounts of money. Yet and still, this system is borked.

Players in my health care team, or, places to duplicate info and mishandle data:

1. Health plan (we pay $890/month private insurance) https://www.deancare.com [note 2]
2. Clinic — almost all my care and equipment comes from staff who work for https://SSMHealth.com They get paid by 1, 5, and 6
3. Small mental health group, home to the "in-network" APNP who deals with my psych meds. https://madisonpsychiatricassociates.com Paid by 1, 5, and 6
4. Family-owned and -run pharmacy, which gets money from 1, 5, and 6 https://www.ipcrx.com/pharmacy-profiles/2018/neuhauser-pharmacy-madison-wi
5. Navitus the pharmacy benefits manager, https://medicarerx.navitus.com co-owned by SSMHealth and Costco. 1 pays them administrative fees to pay 2, 3, and 4
6. Medicare (US government insurance, $170 monthly deducted from our retirement checks) and the only non-profit. Pays most of the bills for 2, 3, 4, and 5.

Note 1: (I’m not going to attempt to spell out what an EOB is. A handful of places try to explain in plain language: https://www.carepartnersct.com/wellness/how-read-your-explanation-benefits-eob

Note 2: I’m super lucky that MyGuy spent 20 years working for #1; he does a great job analyzing the EOBs, among many other skills.

cross posted to the wonderful podcastjoy community

An Arm and A Leg is a podcast focused on the cruel cost of U.S. health care. Experienced radio producer Dan Weisman personally crashed into this issue, looked around for help, and realized this was a beat that needed covering. He does original reporting and boosts the knowledge of dedicated fact-hunters and advocates from around the U.S.

Even though the topic is dire, the show is funny and well-edited. What If This Podcast Were A Musical is indeed a musical about the cost of health care!

The Why Are Drug Prices So Random episode turned on a very bright lightbulb for me re pharmacy benefit managers. PBMs are the 41 for-profit companies which determine how much U.S. folks pay for a prescription, no matter whether we have health insurance.

I’ve poked Dan about his wanton use of "crazy" as an all-purpose negative adjective and the lack of transcripts for An Arm and A Leg, and he promises to do better.

In the meantime, a sober evaluation of PBMs from STATnews:

( 350 words about PBMs )