Controlling spending through price

Tufts Health HMO, rated best in the US by US News, just sent a note that included changes in co-payments on procedures.

Co-pays go from $25 to $600 for Cat scans, MRI scans, pet scans, breast biopsies (which can consist of removal of a cysts with a BIG needle), colonoscopies and other procedures. Where the procedure happens (office, clinic, or hospital) can determine the co-pay for the exact same procedure.

Brand name drugs will be removed from a tiered system of pricing to one that includes only generic drugs, in that the price of the brand name will be the co-pay plus the difference in cost to Tufts Health Care between the two drugs. Currently for a drug such as Wellbutrin, the generic co-pay is $15 and the brand name co-pay is $45. The new policy aims to double the brand name cost at least from examples on the website to $90 per month cost with this example.

The current cost of a family policy is about $1300 per month with the drug benefit above, or about $15,600 per year. Throw in one colonoscopy (recommended every 5 years but per person, not per family) and a cat scan for a heart, brain or chest, plus say one Wellbutrin and celexa standard dose for a post trauma and depression complication at $180 per month (remember my work), and that can come to over $19,000 per year. Breathtaking concept for most.

The generic versus brand name drug issue will be for another post. However, this is a process using pricing as the incentive to curb spending. Yet ‘best practice’ as stated by the medical community can be quite expensive in the real world, and the underregulated world of generics demands caution in my mind.

Update: Replaced unregulated with underregulated.