Cost control: Your go-to guide to reduce health care costs

Lupus Foundation of America

Resource Content

When 24-year-old Lindsay Nason developed a hive-like rash on her neck and shoulders, her doctor suspected shingles. But after a few blood tests and a referral to a rheumatologist, Nason discovered in 2009 that she had lupus. As a fundraiser for a nonprofit organization in New York City, Nason had great benefits and a good health insurance policy, but even so, she quickly realized she couldn’t keep up with her medical costs. “I was spending $100 or more just on co-pays every month with visits to my primary care physician, rheumatologist, and ophthalmologist,” she says.

Unfortunately, Nason’s situation isn’t unique; many people with lupus find themselves in the same leaky boat. In fact, the average person with lupus sees three or more doctors before even getting a diagnosis. That was the case for 42-year-old Karon Beasley of Woodstock, GA. After years in and out of doctors’ offices—and dozens of referrals to specialists—Beasley was finally diagnosed with lupus in 1999, five years after her symptoms started. The delayed diagnosis compromised her organs, resulting in complications ranging from low blood pressure and tachycardia (an abnormally fast heartbeat) to cognitive impairment and nerve pain. The medical expenses racked up.

Circumstances like Beasley’s and Nason’s can devastate even the thickest wallet. And while you can’t stop seeing your numerous physicians, you can find ways to lower your health care costs.

Know Your Benefits

If you’re among the 15 percent of Americans who are uninsured, getting some type of coverage is the first step. Medicaid is an option for some people, but limitations vary from state to state, and coverage is often restricted to children and people with children. Health discount cards offer another alternative. The cards aren’t insurance, but they do offer lower prices at pharmacies, hospitals, and clinics.

If you have health insurance, select a plan that offers the greatest bang for your buck. Are you always visiting specialists? Choose a policy that features low co-pays, even if you have to pay steeper premiums. “People with lupus are on medication and they may have multiple doctor visits at any given point, so a lower-deductible, higher-premium plan may be in their best interest,” says Carla McSpadden, R.Ph., C.G.P., director of professional affairs for the American Society of Consultant Pharmacists.

Once you have a plan, take stock of the physicians, facilities, and providers in your insurance’s network—and stick with them. And when your in-network physician refers you to a specialist, make sure that provider is in your network, too. “Staying in-network can save you hundreds, even thousands, of dollars a year,” says Christie Hudson, vice president of Medical Billing Advocates of America. Because insurers use their muscle to negotiate discounted rates with in-network providers, out-of-network providers can charge as much as 50 percent more for their services. And don’t forget that you’re on the hook for the portion of the bill that exceeds what your carrier considers an appropriate fee, Hudson says. “When you go out of network, you’re not protected from unreasonable and customary charges,” she says, meaning facilities can bill basically whatever they want.

Even in-network prices can vary by as much as 500 percent, so do your research. You can start by visiting the U.S. Department of Health and Human Services Web site to find cost comparisons for hospitals and medical facilities across the country, as well as detailed information on what Medicare pays for common procedures. “This is a helpful guide even if you’re not on Medicare,” says Hudson. “Just expect to pay about 25 percent more than the Medicare allowance.”

Manage Your Meds

Prescription medications can be the largest component of out-of-pocket expenses, particularly for people like Beasley, who once took 24 medications every day. The good news: There are a number of ways to cut back on pharmaceutical costs.

Go generic. Whether you pay full price for your prescription or only your insurance co-pay, you can save up to 80 percent by going generic. “Generic medications are just as good as brand-name products,” McSpadden says. “Oftentimes, these drugs come from the exact same plant since many brand-name pharmaceutical manufacturers own generic companies as well.” You can ask your doctor or pharmacist about generics or check online. Your doctor may not always be aware of a generic counterpart, however. Beasley only discovered the osteoporosis drug Fosamax® had a generic equivalent when she saw a sign at her pharmacy. “It was a huge savings for a drug that was not covered as a brand, and my doctors didn’t even know about it,” she says.

Take advantage of Patient Assistance Programs (PAPs). Most pharmaceutical companies have patient assistance programs that can cover medication costs for you. “Most classes of medications have at least one or two drugs that are available through a PAP,” says Richard Sagall, M.D., president of, a nonprofit organization that provides health care consumers with a free pharmacy discount card and links them to low-cost and free programs. “But all PAPs require some physician involvement, so you have to ask your doctor to complete the forms for you.”

Bargain-shop. “Call a couple of pharmacies in your area and ask for a price quote,” suggests McSpadden. “Then choose a pharmacy that’s convenient for you and tell them the price you were quoted. They will almost always match it.” Many will even accept coupons  from competitors.

Ask for samples. In some cases, your doctor can provide samples at no cost as long as the manufacturer provides them. Just make sure to tell your pharmacy about the samples you’re using. “Most people rely on their pharmacy to do drug interaction checks and contraindication screenings, and the only way they can do that is if they have a complete list of everything you’re taking,” McSpadden says.

Use a pharmacy card. The drug discount card is good at more than 60,000 pharmacies. There are no income, age, residency, or insurance requirements. Just download the card—or the iPhone app—through the group’s site. “With the card, you can save up to 80 percent off the cash price of drugs,” says Sagall. The card is mainly designed for people who are uninsured, but Sagall says that insured patients sometimes can get a better price by using the card than what their co-pay would be.

Sign up for a 90-day supply. Some medications are available in a 90-day supply—either through your local pharmacy or your insurance company’s pharmacy plan. “By going through my health insurance’s pharmacy benefits manager, I get a three-month supply of Plaquenil® for the same price as a one-month supply at my local pharmacy,” says Nason. “Not only is the medication delivered right to my doorstep, but I can log in to my health insurance Web site and ask for refills or request new prescriptions, and the pharmacy benefits manager will take care of all of it.”

Split your pills. If your medication is a pill or tablet that can be safely divided in half, ask your doctor to prescribe a higher dose. If you’re on 20 milligrams of a medication daily, you can purchase a 30-day supply of a 40-milligram dose for the same price and divide the tablets in two. That one step will cut your prescription cost in half and make it last twice as long. However, this tactic works only when different strengths of the drug are the same price, and, according to McSpadden, that’s the exception, not the rule. “Most of the time 10, 20, and 40 milligram tablets are going to be incrementally more expensive,” she says. So ask your doctor and your pharmacist before splitting tablets. And buy a tablet splitter. They’re available at most pharmacies and can help ensure you’ll get the most accurate cut.

Check your insurance drug list. Still can’t get the cost of your medications down? Ask your doctor if there’s a comparable medication on your plan’s preferred-drug list. These medications will run you more than a generic, but they may be less expensive than other brand-name drugs. And keep in mind that you don’t have to fill your entire prescription. “A pharmacy can always dispense less than a doctor prescribed,” says McSpadden. “If, for cost reasons, you can only spend $30 on medication, tell the pharmacist you want $30 worth.”

Be Your Own Advocate

Ask your doctor upfront how much you’ll be charged for a particular medical service or procedure. Prices vary widely among health care providers. According to a 2009 report by the insurance industry trade group America’s Health Insurance Plans, some out-of-network doctors charged patients as much as 1,000 percent more than the Medicare reimbursement rate for the same procedure.

The key to avoiding a similar outcome: negotiation. “There’s absolutely nothing wrong with trying to negotiate prices,” says Hudson. But do your research first. Call your insurance company and find out how much they will pay for the procedure you need. Relay the information to your doctor and see if the price will change. And, if you can, offer cash and then seek reimbursement from your insurance company, if you have insurance. If you are able to pay for care upfront, your doctor may offer a lower price because he won’t have to deal with third parties, which increase overhead costs.

“Staying on top of health care costs is a constant process of asking and being proactive,” says Beasley, who was able to slash her prescription costs by asking her doctor for samples of drugs that were not covered under her insurance. Most doctors understand that medical costs are a financial struggle for people, especially those with a chronic condition like lupus. Explain your circumstances to your physician, and you may be surprised by the discounts you receive. Just do it upfront, before a procedure or exam, so you have more negotiating power, says McSpadden. If your doctor isn’t willing to come down in price, you may be able to find another who will.

When your bill comes, if you’re unsure about extra costs or penalties, stick up for yourself. Ask for an itemized bill and check it line by line. “A lot of hospitals send summary statements so you can’t see the specific items you’re being billed for,” says Hudson. “If you request an itemized statement, you’ll be able to see the breakdown of charges.” Hudson believes the majority of medical bills have errors in them. If something looks suspicious (like five Tylenol® when you had only one), question it.

Feeling overwhelmed? Don’t be afraid to ask for help. Medical Billing Advocates of America has 100 patient advocates across the country who are trained to find errors on medical bills and negotiate with physicians. “If you’re not getting anywhere with a billing department and you want to know what something means, an advocate can find out,” says Hudson. “And they can also fight erroneous charges for you.”

Take Advantage of Tax Breaks

Even if you’re able to keep costs to a minimum, you’ll still be stuck paying out-of-pocket expenses for your co-insurance, deductible, and meds. All of those costs add up. But there are federal programs that can help.

The government allows taxpayers to deduct any medical bills that exceed 7.5 percent of their adjusted gross income. You might even consider lumping expenses into a single year (when you can) to reduce your taxable income. Just make sure to keep your receipts. “Whether you go to Walmart and buy solution for your eyes because you wear contacts, or you’re taking medication because you have high blood pressure, keep those receipts,” advises Hudson. Every little bit adds up and might help you move past 7.5 percent of your adjusted gross income.

Another tip: If your employer offers a Flexible Spending Account (FSA), sign up. These accounts allow you to set aside pretax dollars for medical expenses ranging from major surgery to a bottle of Advil®. The money is deducted from your salary before any taxes are taken out. So when you set aside $1,500, for example, you save more than $400 in taxes a year. “If you know you’re going to have a large medical expense, like surgery or prescription eyeglasses, this is a great way to save ahead and plan for these kinds of costs,” says Nason.

But there is a caveat. Beginning Jan. 1, 2011, in order to be reimbursed through an FSA, a doctor’s note or prescription is now required for over-the-counter medications, even those as basic as Zyrtec® and Midol®. And beginning in 2013, annual FSA contributions will be capped at $2,500.

Make Prevention a Priority

You may not be able to predict a lupus flare, but for routine health care, the best cost-control program is prevention. Make sure you get regular checkups and screening exams from your doctor, dentist, eye doctor, and specialists so potential complications can be dealt with sooner—and, thus, cost less to treat.

Further, take advantage of companies and events offering free programs, such as flu shots and blood pressure screenings. “Local community churches, organizations, and pharmacies often host health fairs or similar events,” says Beasley. “These events often offer free glucose testing, blood pressure checks, bone density tests, and other screening exams. And they give out sample products and great coupons.”

Lupus can knock you off your feet, both physically and financially. But you can help lessen some of your money worries by being proactive about your medical expenses. Ask questions. Do your research. And review your itemized health care bills.

By being your own advocate—or having someone who can advocate on your behalf—you can take charge of your physical, emotional, and financial health. And then, you may just find a few more dollars in your wallet.

To Learn More:

NeedyMeds is a nonprofit that provides information on 3,000 programs and 11,000 free and low-cost sliding-scale clinics nationwide, all free of charge.

Healthcare Blue Book offers a free consumer guide to help you determine fair prices in your area.

New Choice Health Inc. is an online comparison-shopping tool that helps consumers locate medical facilities and compare medical procedure costs for common procedures.

PriceDoc connects health care providers with consumers looking for medical and dental procedures and enables consumers to compare and negotiate pricing on medical procedures in a given location in the United States.

Hospital Compare is a tool from the U.S. Department of Health and Human Services that helps consumers compare hospital charges and coverage costs across the country.