I would bet you that if Viagra (and other boner pills) all of a sudden became a Tier 4 drug, that this whole problem would go away, quickly.

I would propose calling it something other than "insurance."
What the hell kind of "insurance" is it that, the more you need it, the less you get? Yet another sign that something is very wrong with the current system.

With Tier 4, insurance companies abandon the notion of insurance and simply become inefficient versions of savings banks.

The system will eventually collapse and be replaced. As Herbert Stein said, if something can't go on, then it won't.

I ran into this crap a few weeks ago -- my Dr. gave me a scrip that was going to cost $250.

I didn't know that, of course, until I went to get it filled. Thankfully, the folks at Walgreen's told me the cost BEFORE they filled it, so I got it switched.

But the fact is my insurance company changed to this model without telling anyone.

They also dropped the biggest kid's hospital in the area (and the Midwest, for that matter) and a bunch of other doctors out of the network for some reason. Again, without telling anyone -- we only found out when the $951 bill arrived last week.

Something has GOT to change. I just wish my address wasn't it (good chance it'll be in Vancouver soon).

I could understand putting novelty drugs on Tier 4, and making people pay extra for drugs that, ...say clear up pimples.

But the drugs on Blue Cross Blue Shield North Carolina's Teir 4 list are for treating Hep C, cancer, antibiotic resistant bacteria, anemia, etc.

I strongly support a universal health coverage program, but I hope that no one thinks that this will solve all of the problems. The best cost management system I have heard of is a combination of what the VA does to track the treatment of their patients and support strong preventive care for these patients along with Oregon's approach to treatment prioritization.

Prevention matters a lot. It has to be fundamental to any reform. Cost management will always exist, but it has to be done in a sensible, predictable manner. That means limits on amounts spent on the oldest and sickest while still keeping them comfortable. It means telling the medical frauds like chiropractors that they are not real doctors and that they will be reimbursed, if at all, as masseurs. It also means that we need to have separate funding for research and experimental treatments and that we will not encourage every hospital in town to have a heart transplant team and three of every toy that GE makes.

Any healthcare plan administered by health insurance companies will fail. They will just pocket whatever money they get, and keep on denying any claim over 500 dollars. They will keep on raising co-pays until people can't afford them. They will keep restricting access to doctors.

And anyway, until we break the back of the AMA, we won't have enough medical professionals to take care of people anyway. Until we build more colleges, we won't have the room to train more doctors or more nurses.

Capital dictates health care costs be borne by the sickest. Until capital's reign is deposed, Americans will have no other choice but to obey it, and hope they are not called upon to bear a catastrophic disease that wipes them out economically.

Some might ask, "What about the overriding need for market capitalization?" At least they understand the overriding ideology that governs our political economy.

Market, commies, hip replacement, blah blah blah.

I cannot complain about my healthcare plan since it is paying for Avastin ($20,000 every two weeks) to save my life. Diagnosis: metastatic breast cancer to the liver, lung and spine. However this article struck dread in my heart, which I really don't need more of these days. THere's this white-blood cell enhancing injection I have to give myself every week at a thousand dollars a pop. And of course, tens of thousands worth of chemo every month.

I hope we get universal health care before I'm dead. And I hope to God they don't move the goalposts on my husband's insurance - and that his company stays in business and keeps him employed. Because all of these factors seem intertwined with the number of extra days I get in this lifetime.

We feel for you, Leila;

Our circumstances aren't anywhere near as dire but there's little doubt that without my current job and current health plan my wife wouldn't be here now. I'm fortunate that I sort of like my job because if I didn't I'd be stuck here anyway. Still, every year when my employer re-negotiates with our "insurance" carrier I'm weak in the knees.

What the hell kind of "insurance" is it that, the more you need it, the less you get? - Thersites

For Leila's benefit, here is today's enjoyment.

So Thersites, I gather you have sex insurance?

thersites hit it out of the park upthread when he wrote - "What the hell kind of "insurance" is it that, the more you need it, the less you get? Yet another sign that something is very wrong with the current system." This new Tier 4 crap is just another way for health insurance companies to screw consumers.

God bless you, Leila. I hope you have a miracle happen to you. I will say a prayer for you...

Kevin, how is Tier 4 clever? I really hope you were being facetious.

Hang in there, Leila. I hope for the best outcome for you.

There are some W. Bush Americans who complain about how the markets work for their health care. The do not understand their own ideology when it is applied to them, which simply does not value their inputs to the economy enough to provide them with adequate health care. When the market does not value others' economic inputs, like immigrants, laborers, retail clerks and poor children, and witholds decent health care coverage, W. Bush Americans think that is fine and logical. It is only when this market logic applies to them that they have a problem with it.

The next time a W. Bush American complains about the poor health insurance coverage they have, point out to them their value to society does not warrant better health care.

(I am not writing about Leila. [Healing thoughts.])

I asked my employer, Weenie. No such luck.

Thersites - man your benefits program sucks!

Weenie -- I asked for a rider. It got very quiet in the personnel office. Then they asked me to leave.

My employer went to a drug plan like this a couple of years ago. The stated idea is that by having employees pay a percentage of the drug cost, the employees will make an effort to choose lower cost drugs, such as generic drugs. From a purely economic point of view, this makes sense in terms of establishing incentives.

Where is breaks down is in the case of someone like Leila, who needs extremely expensive drugs. I think my employer's plan has a maximum co-pay amount, but I have been lucky that I have not had to verify that fact.

I am in favor of a Canadian-type single-payer system, but this could be one problem that even a single-payer system cannot solve. Even a single-payer system will encounter some drugs or other medical therapies that it cannot afford to pay for.

Choosing lower cost drugs is only an option when they exist, although I suppose the "option" of non-treatment is always available. This is one harsh policy.

I did a little snooping on Avastin. It appears that the price is set by the pharmie (Genentech) and that it is not related to the actual manufacturing cost, but some arbitrary price they have decided that the "market" will bear.

I think it's fair to point out that this whole problem began -- as the story was fair to point out -- with Medicare, otherwise known as the government. While the story tries to spin this as a problem with the private market, in fact, government programs have the same cost pressures, and a political pressure to boot: spending tax dollars.

I'm not taking any sides here, just pointing out that arithmetic is a cruel master. Profits are a problem on the private side (say Democrats), but government has its own set of pressures and problems, and the politics of budgeting is no small thing.

I realize that this is asking the forbidden question, but why should pharmaceutical companies develop drugs based on the understanding that they will get away with charging an average person's annual income on a month's worth of dose? There may be an argument that avastin would never have been developed without the expectation that it would become the breakthrough profit center for the company. But if that was the core expectation, then the system is badly warped even at the level of R&D management. Looking up avastin on google, it's an inhibitor of a signaling molecule that stimulates growth of blood vessels; by inhibiting that signal, it is thought, tumors will not be able to grow as well because they will be starved for a blood supply. On the basis of what this compound does, it shouldn't be harder to make than lipitor or lots of other drugs; it's just that it's still under patent and the pool of eligible patients is smaller, so Genentech has priced it through the roof. The other reason the price is so high is because the target population is pretty desperate. You can live without lipitor and take your chances, since it deals with a statistical danger of something that hasn't already occurred.

Perhaps liberals should be picketing Genentech's headquarters in the bay area. The term bloodsucker doesn't begin to do them justice.

And in answer to the question: What is the alternative if we want to develop drugs like avastin, other than the actions of entrepeneurs like Genentech? Well here's one right from a once-highly successful sector. Let the government fund the R&D on a cost-plus contract. I suspect that we could have gotten avastin for less than the cost of one nuclear submarine. And by the way, I'm not arguing that we should never have built submarines, I'm arguing that as a national economy, we could be saving a lot of money by preventing companies like Genentech from extracting monopoly profits that they get by owning important drugs.

Moreover, there is an element of cart before the horse here. The basic understanding of angiogenesis (ie: what controls growth of blood vessels) came from publicly funded research, including zillions of dollars of NIH grants. In this sense, the basic research was done pretty much on a cost plus plan (Judah Folkman applies for a grant, does the research, and publishes his findings, thereby making the knowledge public sector). There's no reason that drug companies couldn't take the knowledge gained from such R&D programs and manufacture drugs, but it would be a system in which avastin would be manufactured and sold at the price of a generic drug.

Not only that, but the public funded the basic research, so the public should have some ownership in the drugs that come out of the basic knowledge base. The way that ownership is asserted is by regulating the abuse of patent rights by the drug companies.

Who knew that "Tier 4" was what it was called? We just knew that is was called "Your prescription plan only covers a fraction of this, so if you don't want your kid to die you'll fork over $800-1500 a month for the next six months." Dead infants are really bad PR, so we were also told that there was state funding for low-income families to get the drug, and that the pharmaceutical company that made the drug also funded a "charitable" program (at a heavy tax deduction) for people who needed the drug but couldn't get state funding. And the insurance company could get away with it because everyone else was willing to pitch in and stop babies from dying when the insurors decided not to.

For all the advantages the Canadian single payer system, coverage of expensive drugs is not a strong suit. E.g., Ontario doesn't normally cover out patient drugs. So, we pay $4500 every 8 weeks for Remicaid to treat my son's ankylosing spondolysis. Fortunately, my insurance reimburses us (for now). The irony is that drugs weren't covered when the Canadian systems were set up because drug costs were such a small part of health care expenses that it was thought that public coverage wouldn't be necessary.

For all the advantages the Canadian single payer system, coverage of expensive drugs is not a strong suit. E.g., Ontario doesn't normally cover out patient drugs. So, we pay $4500 every 8 weeks for Remicaid to treat my son's ankylosing spondolysis. Fortunately, my insurance reimburses us (for now). The irony is that drugs weren't covered when the Canadian systems were set up because drug costs were such a small part of health care expenses that it was thought that public coverage wouldn't be necessary.

The politician who pushed Canada into universal public medicare, Tommy Douglas, was voted the Greatest Canadian a few years ago. The American politician who finally achieves that goal in the United States will surely be considered right up there with the great American politicians of all time. Good luck to you all, because you are the ones who will actually make him or her. It is a noble cause.

From the linked piece:

"The possibility of changing that insurance scares them, even if it's likely a change for the better."

Actually, what scares them (i.e. middle-class voters with health coverage) is the idea that universal health care will be better for "those people" (i.e. the mostly-poor and near-poor now uninsured) but worse for themselves. They think it's all a zero-sum game, and that they'll have to pay higher taxes to provide for the poor.

Our strategy should be to emphasize stories like this, i.e. how middle-class, insured folk also get screwed by the system.

Another case that would be useful to publicize is how, a few years ago, a cardiologist in (I think) Redding, California did unnecessary cardiac catheterizations on a slew of people. Some died, others became permanently disabled because of the procedure. And this skank MD chose his victims *because they had great insurance coverage*. It was middle-class folk with good jobs, not the poor uninsured or Medicaid patients, who were on the receiving end of this screwjob.

We have to stop talking about average statistics for, say, infant mortality and how badly we stack up against other rich nations. When people hear that, they say to themselves, oh, that's just because of our "diversity," i.e. those brown people who eat fatty foods and use IV drugs, bringing down our averages again.

The assumption among middle-class voters is that health-care for middle-class Americans is better than health-care for middle-class Canadians, French or whomever.

These are the unspoken assumptions behind the "best health care system in the world" chant, and we've got to address them head-on.

Ugh, I guess I'll be the anonymous dickhead here, but what society can possibly afford to spend hundreds of thousands for 20 week on preemies on one end and end of life care on the other? All while plenty of relatively cheap to treat conditions go untreated due to quirks of healthcare coverage. Anyone who talks about healthcare as a right (it isn't, look at the Constitution), rather than cost v. benefits with serious fiscal constraints is just putting their head in the sand. There's real fiscal consequences to spending lavishly on people with terminal conditions -- that's money that either has to be raised through taxes or by taking money away from education, infrastructure, etc.

I suspect that many of the tier 4 drugs are not freely available in Europe or Canada either. They may be marginally better than cheaper drugs or they may marginally improve quality of life for people taking them, but they're not worth hundreds of thousands of dollars of social good.

What this means for the Medicare Rx participants is that you blow into and out of the coverage donut hole rapidly, in a couple of months in many cases, with several thousand $ out-of-pocket expense.
The Medicare Rx program is seen to be just catastrophic drug coverage.

People already go to Canada for drugs, why not for insurance policies?

I'm ready to sign up.

Again, insurance companies need to be taken OUT OF THE LOOP and replaced by a publicly controlled, owned and OPERATED MUTUAL FUND to pay for healthcare.

What got us into this mess is INSURANCE COMPANIES which horned their way into the health field by jacking up malpractice insurance rates so high doctors HAD to raise their prices or retire.

Many people can remember when there was no such thing as health insurance because it wasn't needed.

WE NEED VERY MUCH to take the profit OUT of healthcare.

INSURANCE COMPANIES SELL INSURANCE.

THE DON'T PROVIDE HEALTHCARE.

It seems like health insurers are taking the lead on destroying the commonly held belief of what insurance is supposed to do. They way I remember it, you pay a premium, they insure you against catastrophic financial losses. To pay a premium and, by chance, get diagnosed with a condition that requires a "Tier 4" drug, requiring the outlay of potentially tens of thousands of dollars per year, bastardizes the whole concept. You're paying a premium, but you're still exposed to a hell of a lot of risk.

Basically, we buy health insurance because we don't want to be bankrupted by medical bills. If you buy insurance, but could easily find yourself bankrupted anyway…why the hell bother? For a lot of people broke is broke; a $20,000 medical bill is no more affordable than a $200,000 medical bill.

If my tier four drug copays increase I know I will not be able to afford the drug. Unfortunetly,(other than no drugs for me), is if I stop taking the drug I will then be immune to it's benefits in the future. That means one less drug I can safely take and a higher chance to mutate my illness. Thanks guys! Live on the streets and afford meds I need to live, or die.

i have hep c , fed emplyee insurance( Kaiser perm) and they refilled the interferon Jan 3, when it was 300$ This was not part of the open season contract. It was just a ripoff, like being in the wrong place of town at midnight.

This is why the USA is going downhill.