Comment by vjvjvjvjghv

Last year I needed to get blood work done, some of which may or may not be covered.

It took me two weeks, dozens of phone calls, and multiple "escalations" to learn what would be covered and what the price would be if it wasn't

Totally insane. The kicker is that after all that, the price I was billed wasn't even the price I was given (thankfully it was less though).

"And everybody would get the same price. This whole business with PBMs that are owned by the insurance companies, discount cards and other shenanigans just invites corruption."

It's hard to say that it isn't racketeering at this point.

"Specifically, a racket was defined by this coinage as being a service that calls forth its own demand, and would not have been needed otherwise."

There's demand for the meds, but the demand for discount cards, forcing people to use specific services/companies, and related programs is all invented by the companies themselves.

Health insurance in general is the problem; PBMs/discount cards are just a cherry on top. Insurance is fundamentally incompatible with clear and consistent pricing.

> "Rome said the companies seem to be maximizing prices while negotiating discounts behind the scenes with health and drug insurers and then setting yet another price for direct-to-consumer cash-pay sales."

This sounds like typical negotiating 101. You know you are going to be forced to lower from your starting position, so increase your starting position so when you do negotiate down you are closer to where you wanted to be.

As a european living in the US, the idea there is a market at all is laughable. I tried to get price quotes for treatments several time just to get a "well, it's hard to say" or "it's very complicated".

> This describes the biggest problem in US healthcare. No clear and consistent pricing.

For anyone not in the US wondering if this is an exaggeration, here is my history of buying prescription drugs.

1. For years, when I had insurance through my employer, I'd go the the nearest in-network pharmacy, which was Rite-Aid, for them. Those insurance plans always had a copay which was typically $10-15.

It was this way across several different insurance providers I had over the years at that employer. (For non-Americans wondering why my insurance company changed so often, it is common for employers to frequently switch providers to try to save money. Besides that being annoying because it means frequently changing coverage limits, it also means frequent changes in what doctors and dentists are in-network).

2. I saw something about Walmart's generic drug program. They were selling many generic drugs for a cash price of $4 for a month supply and $10 for a 3 month supply. Most of my drugs were included, so for those I switched my prescriptions to Walmart and didn't use insurance.

3. Later, for my drugs not in Walmart's generic drug program, I found that the GoodRx app or website could usually provide a discount coupon that would bring the cash price with coupon down below my insurance copay.

The GoodRx discount could vary significantly from pharmacy to pharmacy so I had my prescriptions split across two pharmacies.

4. My employer downsized and could no longer afford to provide insurance. I switched to a plan purchased on my state's Affordable Care Act (ACA) marketplace. I made too much money to get a government subsidy on my premiums, but not enough to afford a marketplace plan in the top two of the three tiers of plans (gold and silver). I had to settle for the third tier, bronze. That basically meant bigger copays and/or bigger coinsurance on everything, including drugs, than I had when I was on plans through my employer. Walmart generics + GoodRx coupons continued to be how I bought drugs.

5. I eventually switched to an HMO plan from the ACA marketplace, when rising costs made it so even the bronze non-HMO plans were too expensive. This meant I had to switch doctors to one that worked for the HMO (Kaiser), and the only in-network pharmacy was the one from the HMO.

It remained cheaper for nearly everything to continue with Walmart and GoodRx. The only drug I regularly got through Kaiser's pharmacy was generic Lipitor. That was $0. I refilled one of my other prescripts at Kaiser once, and my out of pocket came to twice what that drug was at Safeway with a GoodRx coupon.

I didn't try any of the others through Kaiser because there was no way that I could find to get the price other than actually getting the prescription filled there. Even though it was a Kaiser pharmacy, which is located in a Kaiser building and only takes Kaiser plans (and maybe people paying cash), they have no way apparently to answer the hypothetical "If I get drug X and I have Kaiser plan Y and my ID number is 12345678, what will my out of pocket cost be?".

I would have expected that one of the benefits of an integrated system like Kaiser where it is one company basically providing all of your health care except for some special services they contract out for would be that they could tell you the damn costs. I would have expected that when I'm in the doctor's office and he gives me a new prescription that on his terminal it would have the cost of getting it filled in the Kaiser pharmacy that is in the same building.

Nope. So I'd have to waste his time and mine getting out my phone, looking up the drug he's about to prescribe in the GoodRx app, and then decide where I want it. A nice thing about the GoodRx app was for Walmart if they did not have a GoodRx coupon because the drug was in Walmart's generic program GoodRx would still include it in the listing, showing the cash price so I didn't have to separately check Walmart's generics list.

6. It does get better when you get older. When I turned 65 and switched from a marketplace plan to Medicare I had to choose an insurance company that offered a Medicare drug plan. You can enter all your prescriptions on Medicare.gov and you can enter 5 pharmacies and the listing of available plans in your area will show you the annual total (premiums plug drugs) for each plan for both getting your drugs at the cheapest pharmacies on your pharmacy list and for getting them via mail order. By default it sorts the list by lowest total.

You still have the hassle of plans possibly changing each year. My plan on my first year went away. It was a $0 premium and $0 for all my drugs. There is still a $0 premium and $0 for all my drugs plan available for 2026, but I'll have to change pharmacies to one less convenient.

The above is if you choose regular Medicare when you enroll in Medicare. You can instead choose Medicare Advantage. The way Medicare Advantage works is instead of providing your medical coverage itself Medicare pays a private insurance company to do it. The plans offered by those private insurance companies broadly look a lot like the marketplace plans that offer on the ACA marketplaces or the plans they offer through employers.

They are usually pretty cheap, often with no premium from the insurance company (although you still have to pay a premium to the government for Medicare). Some even have negative premium plans. They also have most of the annoyances of ACA marketplace and employer plans, but there are usually ones that include drug coverage similar to the part D plan coverage for people on regular Medicare.

Here in Brazil, we have something called 'Genéricos.' These are essentially the same medications as the brand-name versions, produced with the same chemical ingredients, but they often cost half the price, sometimes even cheaper than that.

Insanely comical.