Comment by throwway120385
3 days ago
All I'm going to say is that Optum Specialty Pharmacy is the sole source that UHC will accept for a lot of special drugs. For example UHC offers insurance for IVF including a separate cap for medications, but if you use their insurance you have to order through their subsidiary Optum Specialty Pharmacy and the prices triple or quadruple over MSRP if you buy from OSP using insurance versus if you pay cash. They also won't tell you this until you're in the middle of a cycle and an order gets held up because you're out of insurance, but since they billed insurance you're on the hook for the remaining several-thousand dollars because if you stop the drugs you're just out the money and the medication and have to wait another month.
I don't know if I can give them the benefit of the doubt on the cancer drugs because of this.
> subsidiary Optum Specialty Pharmacy and the prices triple or quadruple over MSRP if you buy from OSP using insurance versus if you pay cash.
As an European, this is mind boggling.
I don't want you to give them the benefit of the doubt. I certainly don't think they deserve it. I do think, however, that a conversation about "overcharging" goes nowhere until people talk about exactly where charging ends and overcharging begins.
I'd be fine with a 20-50% markup on MSRP to cover billing and administration costs but when the insurer owns the pharmacy they can "negotiate" whatever rate they want and you have to pay it. I don't see it directly in the article, but I suspect they do the same thing with cancer drugs as with IVF drugs and require you to go through their pharmacy for insurance coverage. Insurance plans often have lifetime maximums, and when they set their own prices and collect money from themselves for the medication they sell you they can basically dictate how much actual coverage you get versus someone paying cash. And because you chose "bill insurance" when you ordered the medication, you're now on the hook for whatever additional cost there was versus the cash price. And also they won't tell you what the cost is until after the medication has already shipped.
So it's at least plausible that they're abusing their position as the company that owns the pharmacy and the insurance plan to charge you a lot of money and provide very little coverage and also to gouge you at the very end of your coverage, because that's exactly what they did to my partner and I.
IMO a functioning government would have trust busted an insurer with such strong collusion with a pharmacy.
Yeah, we need to be careful with using something like MSRP because of what that S means. I would rather we find a different baseline more fundamental to the cost of production than something that essentially amounts to "the price is the price". But I'm right there with you, and I think it's a good start.
Anything above what Medicaid pays for drugs/procedures (and maybe a few % over to account for health insurance salaries) is overcharging.
Is that clear enough for you?
The trouble with this cascades as follows:
1) I don't know what Medicaid pays.
2) I don't know that what Medicaid pays is a just price until we define what a just price is on its own merits. Maybe Medicaid pays more than they should.
3) What Medicaid pays could change at any time for any reason unless what Medicaid pays is based itself on some metrics that define otherwise, in which case let's just look at those metrics directly, yes?
4) If Medicaid decides to pay more, is that the new line?
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UHC double-dips because they own Optum even though Optum is "independent". It's fucking disgusting. How they were allowed to buy Optum and didn't have every regulator in the country on the case is beyond me.
I $truggle to think how $omething like thi$ wa$ allowed to happen.
Bastards.
My wife had to quit seeing her doctor of many years a couple of years ago because as Optum has been devouring practices in our area, they stuck her with a surprise bill almost a decade ago and then fired her as a patient without providing even a statement. Now that they own her doctor she can no longer go to that practice even though she was a paying patient for many years.
> fired her as a patient
This is the most absurd set of words I've read in a while.
You have that a little mixed up. Both UnitedHealthcare (UHC) and Optum are subsidiaries of UnitedHealth Group (UHG). UHC never bought Optum. Some parts of Optum were spun out of UHC's IT department so that they could commercialize software they had developed for internal use and sell it to other customers (including some of UHC's competitors in the commercial payer space). Other parts of Optum were acquired or created internally. What is now OptumRx (the PBM) was originally PacifiCare Health Systems. UHG acquired that business way back in 2005 before the Optum brand even existed.
I agree that more reform and enforcement is needed in the healthcare industry but let's at least get the facts and history right.