Monday, January 7, 2013

Big Bills

Young teachers and young lawyers have something very significant in common -- they both learn a lot of new information within hours of having to pretend that they are experts on it. Sometimes I am horrified at what a bad teacher I must have been my first year, especially to the students to whom I taught economics. Despite that my Grandpa literally invented genius concepts in economics and wrote books on them, I could barely define the topic when I took on the class.

In my first year of teaching, I worked for hours every night to prepare my world history lessons and stopped only when I felt ready to face my four freshman classes the next day. At that time -- usually around 10 or 11pm -- I had to decide what and how to teach my one economics class. More than once, the time on the clock caused me to break down in tears. I never thought I could prepare myself in time for the next economics class, and even though I'd still put another few hours in, I was never as prepared as I wanted to be.

There's little I hate more in the academic world than the feeling of being unprepared, but in my first year of teaching, there literally weren't enough hours in the day to avoid that feeling. And so every day, I'd stand up in front of a room full of teenagers and I would teach them what I did know, desperately hoping that it was enough.

As a young lawyer, I have done much of the same -- I learn all that I can, sometimes in the wee hours of the morning, and I craft emails or prepare talking points for calls or meetings about what I do know. When I hit send on an email or dial in to a conference call, I still hope that what I know will be enough; for the time being, at least. Because early on, I also learned the comfort of the truthful admission that I don't know, but I will find out. While I think that much of a young teacher or lawyer's success is about preparation and confidence, I also think that much of it is about honesty, and personality, too.

As a health care attorney, I've been asked many questions about health care reform in the last few years. I've read a lot about the topic and completed countless work assignments for which I researched detailed issues on the Affordance Care Act, or, as some people (not including myself) like to call it, "Obamacare." Still, while the topic of health care reform has intrigued me for years, I don't exactly consider myself an expert on the topic. It's just too darn big of a topic.

I've never had a reason to dig deep into the part of the Affordable Care Act that deals with the elimination of annual and lifetime health insurance coverage caps. In simple terms, it's that part of the law that prohibits my health insurance company from saying -- We'll pay for your medical care up to $X, and then you're on your own. I could dig into this part of the law tonight, but then I'd feel like a first year teacher or first year associate all over again, beginning a new research project at 11:00pm. To spare myself that effort, please just imagine some big disclaimer inserted here -- The opinions expressed in this post do not necessarily reflect the full views of the author, or something useless like that.

With that, here's what I do know:

1.  I have health insurance through my very generous employer.
2.  In the past few months, I have racked up medical bills like never before.
3.  Without health insurance, or possibly, if that health insurance coverage were capped, my family would face financial ruin or I would not be able to get the drugs that I need to survive.

Like any good lesson or discussion, some real-life details may help to flesh out this issue. So let's take the last bill that I received in the mail from Dana-Farber. The bill was for services rendered on October 10, 2012. That was the day of my first chemotherapy treatment. As you may remember, that was the one treatment that went as smooth as silk. It was before my allergic reaction, before the ICU, before the desensitization unit, before neutropenia. Back then, I was as regular as a chemotherapy patient could be. Now for the fun part. I'll give you a moment to guess the total charges for that three-and-a-half hour infusion. $10,000? Maybe $15,000? You could be crazy and guess $20,000. Ready?

$37,266.26. No joke. No exaggeration. That's the truth down to the penny.

I hate talking about money, but I'm guessing that financial issues are some of the most stressful consequences of any chronic illness (ironic, since stress is certainly not helpful in the healing process). So I'll go there and talk about money, at least a little bit, and, as always, only from my own very limited personal perspective.

Even with health insurance, cancer is expensive. In the past month or two, I have paid too many bills to count. Thankfully, most of them (including the $37,266.26 one that I mentioned above) boil down to a $25 co-pay. Inpatient stays, ICU overnights, and surgery have cost a lot more even after health insurance picks up the bulk of the tab. But still, those payments have only been in the $500-$1,000 range. In the end however, my health insurance policy has an out of pocket annual cap per family member so I know that the costs cannot get completely out of control.

I also know that I am blessed to write out a $25 check on a $37,000+ bill, and to have a limit on the annual amount I will have to pay out of my own pocket for my medical care. But this weekend as I paid some bills to Dana-Farber and the Brigham, I got to thinking about patients and families for whom some exorbitant number remains at the bottom line. Although I don't usually look at my medical bills very closely (I gave up trying to keep track), I needed to know more about this 37,266.26 number...

The biggest charge was $18,635.04 for "Trastuzumab Inj Per 10mg." I Googled it. The Herceptin. Ah-ha. 

I kept going. $13,387.40 for "Docetaxel Inj Per 1mg." The Taxotere. Interesting. I remembered back to the Brigham ICU when the bag of Taxotere arrived from Dana-Farber with a slight tear in it. The inner bag had leaked into the outer one and I remember lying in my bed trying to eavesdrop on the conversation between a group of doctors and nurses in the hallway about whether they should still administer the bag. The leaking bag terrified me, and luckily I didn't even have to say so because my fabulous infusion nurse ultimately rejected the bag and made them prepare a new one. I hadn't even thought of the cost of the drugs that likely got (or better yet, darn well better have been) poured down the drain. All I knew is that I didn't want to send anything into my veins that shouldn't have been there. My body was already confused enough.

I admit that parts of that $37,000 bill are still a mystery to me. For instance, I have no idea how much Dana-Farber pays for the Herceptin (although I do know that it comes from a biotech company called Genentech). I also don't know what the bill would have looked like for someone who had made known a less fortunate financial situation. Perhaps it arrives with numbers already slashed? Regardless, without health insurance, I'd have some pretty enormous bills sitting on my desk, and I'm not sure what I'd be able to do about it.

Through my job, I've come to think very highly of the Affordable Care Act, or, at the very least, of the parts of it with which I have worked. Of course, there's a lot that I don't yet know about the massive legislation and the impact that it will have on individuals and on the nation. But I know this for sure -- I like a law that tells my health insurance company that it can't stop covering my Herceptin or chemotherapy or surgery just because I've hit a certain cap. Because patients and families battling cancer or any chronic disease have lots of things to worry about. I can only hope that paying for treatment isn't one of them.


  1. Love all your writings and will add a huge "WOW" to this one, Tara. What an eye-opener. Your honesty and transparency through every aspect of this journey is refreshing. Love ya girl.

  2. This post was a real reality check. Thanks for the info. Hope that you are doing well.

  3. Late to comment, again! But I wanted to comment still because this is such an important post and something that I think about often as I watch the "How much is my benefit worth?" number rise on my insurance (currently several hundred thousand for cancer alone).

    The other part of it for uninsured women is that on average women with out insurance are diagnosed at later stages than women with insurance. Which makes sense when you think about how it can be a matter of time off from work combined with full cost of each doctor and specialist plus the imaging, biopsy, pathology, just to get to the diagnosis.

    And then, at later stages, you're more likely to be talking dose dense chemo which relies on the $9000+ Neulasta shot to keep the patient well enough to continue on the aggressive schedule that makes it dose dense, and radiation therapy which is both costly (over 40K, in my case, at least) and daily for a number of weeks which can be tough on a work schedule.

    Very, very tough situation for so many women. I have no idea if the Affordable Care Act will be enough or not, but I'm thrilled that it's a positive step, at the very least.

    Thank you for taking this subject on, and in a very well written way!

  4. As one of your former economics students, I'll be the first to say that I never once thought you were unprepared and it was one of the best classroom experiences I had in high school. In many ways, the reason I chose a career in finance (though that may be indicative of me still not knowing anything about economics...)

    1. also really glad I found this blog and so happy to see that you're doing well