Mars retiree baffled by huge increase in cost of her medical treatment

Jan. 26--Millie Szymanski wants to know how the charge for the medication to treat her recurring ear infection could go from $3,400 to $10,000 in eight months, an increase even the drug's manufacturer says well exceeds its cost.

A local Medicare consumer advocate, meanwhile, says the increase may be legitimate but the lack of transparency in medical billing prevents patients from finding out. That lack of transparency, he said, can lead to unpleasant surprises when medical bills arrive, particularly at the start of a year, when plan benefits may change, or any time of year a patient changes insurers.

Ms. Szymanski, 86, says the infection in her left ear first flared up in 2014, shortly after she got a hearing aid. She went to see an independent North Hills physician practice that specializes in infectious diseases and was treated intravenously with two courses of the antibiotic dalbavancin.

Under her Medicare Part B benefit with Highmark's Freedom Blue plan, the $3,400 charge was reduced to a pre-negotiated price that ultimately resulted in a total $35 co-insurance payment for her.

The next month, she says, she switched to UPMC Health Plan's UPMC for Life "because all of my doctors were UPMC."

In July, the infection came back. She returned to the same doctors and got the same treatment with dalbavancin, barely giving a thought to the possible cost.

Then the bill came: A $10,000 charge for dalbavancin, which, after the insurance payment and other adjustments, left her with a bill for $1,019.22, a daunting debt given her $2,400 monthly pension and Social Security benefits. So far, she said she has made only an initial payment of $40 toward the bill.

"I was waiting to see what else I could do. I was hoping something from UPMC would come through." She has also filed an appeal with the Medicare contractor that handles billing disputes.

Last month, a statement from the physician practice reminded her that the balance was overdue with a warning to "Contact us or be referred to a collection agency." She was later told the bill was "on hold" until March 1, but Ms. Szymanski -- a widow who lives in a senior independent living apartment in Mars, Butler County -- worries that medical bills like this may force her to move.

"I want to stay here until I die. I'm very active in everything that happens here and I don't want to leave."

The office manager at the physician practice, Romano & Pontzer, said he could not discuss the case because of federal laws that protect patients' privacy. Ms. Szymanski says the office told her the cost difference occurred in part because they had undercharged her in 2014 "and I had better insurance coverage with Highmark in December, than UPMC in July."

Similarly, UPMC Health Plan spokeswoman Gina Pfederhirt said she could not talk about an individual member's coverage but noted that out-of-pocket costs can vary "based upon the plan design purchased in any given year, the amount of deductible that has been satisfied at the time of administration, and other factors, such as the Medicare out-of-pocket maximum.

"Without this information, apples-to-apples comparisons are impossible."

Because both Part B plans called for a 20 percent co-insurance payment and the UPMC monthly premium was only about $30 cheaper, Ms. Szymanski's first suspicion was that dalbavancin, which goes by the brand name Dalvance, was the latest example of a drug manufacturer dramatically raising the price of its products.

But Mark Marmur, the New Jersey-based spokesman for Allergan pharmaceutical company, said the company has not increased the price of dalbavancin since its introduction in late 2014.

He declined to specify how much the drug costs but offered that Ms. Szymanski's $3,400 charge for her first treatment "is in line with the cost of the product. But the second was not."

The medication is not covered under the state-run PaceNet program for low-income seniors, Ms. Szymanski said.

Bill McKendree, coordinator for Allegheny County's Apprise consumer advocate program that helps seniors choose a Medicare plan, said it is not uncommon for clients to call with similar medical sticker shock stories, typically after they change insurers or their benefit plan changes with the new year.

Ms. Szymanski's case "is an example of what happens to the average person when confronted with a significant procedure that they're relying on the insurer to cover and they're relying on the practitioner to be fair and candid about," he said.

The trouble, particularly with Part B outpatient prescription, is that it's not spelled out what's included in setting the price beside the medication, such as nursing care, radiology scans, infectious disease protocols or any other tests.

"There may be a logical explanation from the standpoint of the professional, but there's no way for the patient to know," he said.

And when consumers face a bill that uses unfamiliar terms and vague explanations, "often they simply give up," he said.

With her income barely covering her room and board, Ms. Szymanski doesn't have that luxury.

"It just makes me very nervous to owe anybody anything, and I really don't like the idea of being turned over to a collection agency," she said. "What can they do to somebody living here? Can they take my savings? I don't know. I don't own anything but a 2001 car."

Steve Twedt: stwedt@post-gazette.com or 412-263-1963.

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