Monday, January 23, 2012

On reaching a quarter of a million

In one respect, I am very fortunate in my cancer care: my insurance is excellent. Oxford, Barnard’s carrier, added MSKCC as “in network” fairly recently, a huge advantage. In addition, from the beginning, MSKCC said that they prefer to handle all referrals, so that eliminates a big hassle. Friends have battled Oxford about procedures for which the approval was mysteriously missing or denied, so far I have seen little of that. I am taking the approach that a denial is MSKCC’s problem to negotiate, not mine. (One example: I received a form denying payment for the CT scan in the hospital when I was having trouble breathing. Reason? I had had a CT too recently.)

But I do see bills, a lot of them: two or three from MSKCC each month, one for outpatient services, one for inpatient services, and a separate one for physicians, those I see and those I don’t, like radiologists and pathologists. Being a compulsive user of Excel, I maintain a spreadsheet of all the charges. The entries from December passed a milestone: more than $250,000 in billed charges. Of that, I have had to pay a little more than a thousand in physician and pharmacy co-pays. Over time, I see what Oxford pays. The fraction of the nominal charge varies hugely, typically between about 55% and 90%, but occasionally a lot less.

What accounts for the quarter million? The initial surgery was about $60K, two subsequent hospital stays with IR procedures roughly $40K and $50K. The bi-weekly Avastin infusion cost about $11K (the drug itself $9802; the other drug, Afinitor, was “free” as part of the clinical trial), and the more recent weekly Torisel infusions about $4K (the drug $2334.)  So it adds up.

So in this early phase of 2012 Presidential politics, I think about health care costs. I don’t think my numbers are atypical. Perhaps MSKCC is a bit more expensive than elsewhere. I think about the unemployed who have lost their insurance, and of all the underinsured. No wonder people go bankrupt and lose everything when a family member gets sick. How awful to be seriously ill and have no idea how you will pay for the care you need. But I also think of broader policy. Can our society afford to pay a quarter of a million dollars, if the likely outcome is not a cure, but instead prolonging life by a few months? (Please note: I am not about to forego treatments for this reason.) Finally, I know that a small employer like Barnard pays health care based on recent usage, so I am contributing to future increases: apologies to my colleagues. For 36 years I barely saw a doctor, so maybe it averages out.

I am doing much better than I was on November and December. The breathing problems are essentially gone. The incisional hernia is annoying and causes some belly pain. I am deeply fatigued and have very little stamina. I am taking daily walks again, hoping that will improve. But I am also trying to figure out how to feel and act less like an invalid. I have had a lot of visitors recently (thanks), and am getting out to see people quite a bit. Officially, I begin a year-long sabbatical this month. A year ago I was contemplating how I would use the sabbatical to devise a role I might play after retirement. I was thinking about how I might get involved with influencing public policy on climate change. What should I do with my sabbatical now? I don’t know.

Tuesday, January 3, 2012

Good news for the new year

I saw Motzer this morning.  The news is good.  Somehow I had convinced myself that the unrelenting complaints of the last two months meant that the cancer had advanced, but the CT scan indicates that the various affected lymph nodes are "substantially unchanged" from the last full scans in mid-October. Some perhaps a mm larger, others smaller. He gave me a prescription to address the nausea.  With my already improved breathing, this should make it easier to enjoy the day. I will have a head MRI later this week to eliminate the possibility that the nausea comes from cancer moving to the brain, but they feel that very unlikely.  I will also see a lung specialist so he will be on the case should the pneumonia symptoms return.  So more time at MSKCC. But I am not complaining.  I will continue with the weekly Torisel, and have the next scans in four weeks.