Difficulties and Disparities in Healthcare Access

Increasing healthcare costs combined with insurance complications may result in patients avoiding treatment. The cost of healthcare has become one of the most commonly debated topics in our country. This has become particularly concerning for rheumatologists, who have patients that struggle to afford everything from generic drugs to insurance copayments for physical therapy. With healthcare costs projected to keep rising, this particular topic has become an area of interest for healthcare professionals in our country.

One of the most well-known, and effective treatment options for rheumatologist patients is the use of biologics, which are an essential treatment against inflammatory disorders. However, these drugs are expensive to produce compared with synthetic drugs, and as a result, their costs seem to be rising dramatically. For example, less than 20 years ago, “patients were able to use a TNF (Tumor Necrosis Factor) inhibitor for about $10,000 a year, now depending on which exact biologic drug is needed, costs per year could be anywhere from $20,000 to $60,000” (Aggarwal & Gupta, 2015).

Obtaining accurate drug prices is often a complicated process. However, one well-known website provides accurate drug price comparisons. GoodRx lists one carton of four self-injectable doses of Enbrel at about $8,700 without insurance. GoodRx provides a $3,000 coupon, which still leaves you with an usually high out-of-pocket cost. “The recommended dosage of Enbrel for adults with Rheumatoid Arthritis is one injection per week” (Enbrel, 2020). So, including the coupon, the retail price for a one-year supply of this particular drug is approximately $60,000.

Another area of concern for rheumatologists is the rising cost associated with generic drugs, especially medications used to treat rheumatologic conditions. For example, colchicine is commonly prescribed to treat gout. A one-month supply is about $170 according to GoodRx. Even though colchicine is a generic medication, each patient’s insurance company plays a significant factor when determining their final cost. Each insurance company is different – some patients might pay the entire retail price, while others might pay much less. As a result of the high prices, some patients may just skip their medications completely. As you can imagine, if you are not taking your medications as prescribed, then you increase the risk of other complications. For example, high uric acid levels can eventually progress to cardiovascular manifestations, which has now expanded to a much more expensive systemic disease. Of course, the actual price that the patient pays depends on their insurance plans, which leads us to another complication associated with healthcare in the United States – Insurance Companies.

In the United States, having health insurance coverage is essential in order to minimize the costs associated with getting treatment. However, “in 2018, there were approximately 27.9 million nonelderly individuals who were without insurance, an increase of nearly 500,000 from 2017” (Tolbert, 2019). Each of these patients had to pay the out-of-pocket full price for their medications, laboratory work, and any other treatment that their physician considered necessary for their overall health. However, if they are unable to afford their medication, then their physician would have to substitute their treatment with a less-expensive and less-effective medication. You have probably already guessed where these less-effective medications lead to – poor treatment and poor prognosis for the patient. Thus, having sufficient insurance coverage is a critical component of our healthcare system. However, in the United States, simply having health insurance is not adequate enough to avoiding long-term financial and mental stress.

Imagine that your physician has prescribed a specific medication to treat your illness. The pharmacy notifies you that your insurance provider has rejected your prescription due to a Prior Authorization. A Prior Authorization is required when your insurance company notices that a particular medication is not on their list of pre-approved or formulary medications. The insurance company will send a request to the physician for approval. However, this process is much more tedious than it seems. The physician will have to provide documentation and proof that this particular medication is absolutely necessary for the patient’s health and for managing their illness. This process can span anywhere from several days to several weeks, potentially delaying the treatment for the patient. It seems absolutely ridiculous that a healthcare professional would have to persuade a business entity that particular medication is necessary for their patient.

Unfortunately, Prior Authorizations are not just exclusive for medications, but they can also be required for radiology and diagnostic procedures, such as CT, MRI, CAT, and PET scans. If you present to your physician’s office with signs and symptoms related to a potential cancer, then the physician might determine that a CT scan is necessary in order to make a definite diagnosis. However, when you take the order to the lab, the CT request might be rejected by the insurance provider due to a Prior Authorization. Similar to the medication example provided earlier, the physician will have to persuade the insurance company that the CT scan is absolutely required in order to properly diagnose a potential cancer within the patient. If your insurance provider agrees to the physician’s request, then you can expect a very small co-pay. However, if the insurance rejects the physician’s request, then you can expect to see “CT scan costs that range from $250 on the very low end, to nearly $5,000 on the high end” (How Much Does a CT Scan Cost, 2018). The cost will vary depending on the facility, your location, and whether contrast is required for imaging. In the United States, it is absolutely essential to have an insurance company. However, the insurance company will make you jump through many hoops throughout your relationship with them.