Medical Tourism: Travel Abroad to Save on Healthcare

The following blog post is an American’s first-hand experience of traveling to Mexico to save money on healthcare procedures. Names and exact locations have been changed/omitted, though the details are all true and have been verified by us at NeedyMeds.

 

It is no secret that healthcare in the United States can be prohibitively expensive. Because of this, many Americans opt to get their healthcare elsewhere.

According to a 2015 report by the US International Trade Commission (USITC), between 150,000 and 320,000 Americans travel abroad every year to receive medical care. For uninsured Americans, the costs are often less than half what it would be in the states — even when including travel expenses.

Americans covered by insurance can benefit from getting healthcare abroad as well. Most insurance plans don’t cover dental work, cosmetic surgery, or prescription drugs. These routine treatments and procedures can cost hundreds or thousands of dollars in the U.S.

 

I have needed dental work completed for most of my life, with the main factor keeping me from finishing it as an adult being the price. I had unfinished work from my childhood that left me embarrassed and in pain. After getting a number of extractions more than a year ago that cost over $4000 by itself, my goal to save for the restoration was more than I could manage.

This is not to say I hadn’t saved any money, just that it was many times what I had managed to put aside for all the work I still needed done—all of which is needed up front when paying in the U.S. My options were to continue to wait and save and remain in pain and discomfort, or to find a more affordable way to get the dental work I needed.

My parents have recently retired to Mexico. Their community is served by a dentist who my mother would start going to, and who she would later refer to me after she saved thousands of dollars on her own restoration work. My partner and I planned a trip for early 2019.

 

The dentist (we’ll call them Dr. R) studied dentistry in Mexico City and had further advanced training at Tufts, Harvard, and other U.S. universities. The Mexican government subsidizes his practice due to the advanced training he’s received in U.S. schools. With this funding Dr. R is able to buy top-tier equipment that dental practices in the U.S. would often need to make numerous referrals for their patients to access.

Dr. R can make their own temporary crowns, does orthodontistry, and other cosmetic work that patients are usually sent away from their primary care provider to receive. The locals in the community are often not charged for their care, for which Dr. R is able to provide due to the cash that comes in from foreign patients.

 

My first dentist appointment in Mexico was brief; a few x-rays, imprints of my teeth, some analysis, and making a plan for the next ten days I would be in the area. It’s worth noting here that dental x-rays can cost between $25 and $250 each in the U.S. I was not charged for them or the first hour-long appointment at all.

The plan was:

  • I needed seven root canals and seven crowns for my top teeth. In the U.S. this would cost $400-$5000 for each tooth. I was initially quoted $300 for each root canal and $500 for each crown.
  • I needed five fillings in my bottom teeth. In the U.S. this costs between $90-$300 per filling; I was quoted $120 for everything.

 

Dr. R questioned why doctors back home had told me my teeth needed to be extracted, indicating the root and bone was still healthy and that they could be saved with less extreme procedures without the need for future expensive implants. He showed me my x-rays compared to those that required extraction, and it was disappointing to see that mine did look markedly healthier. Even the teeth that had been extracted looked healthier than the ones I hadn’t — I had elected not to extract them sooner because they were front teeth, and I couldn’t afford to replace them at the time. I chose to feel relieved that I was saving what I have left.

 

The seven root canals were the following morning. Dr. R had called in an endodontist for the procedure, and it took a little less than four hours. I had brought the $2100 that I was quoted ($300 times seven root canals), but was surprised when I was told that the root canals only ended up being $200 each — $1400 for seven root canals, and Dr. R took the extra $700 I had as an advance payment for the crowns which he assured me would arrive before my flight ten days later. I was given antibiotics for a budding infection (which meant I couldn’t drink alcohol for the remainder of my trip) and painkillers; I was not charged for either.

It may be worth noting that there were no fewer than eight “farmacias” within a five minute walk of my parent’s community. Medications are not regulated the same way in Mexico, and prescriptions can be bought by anyone with the money for them [NeedyMeds’ Note: We do not advocate for the use of non-USA regulated pharmacies, especially mail-order].

 

Seven root canals are far from comfortable, though after the procedure the pain was minimal. The next morning I returned for the temporary caps to be put on, which (including the time it took Dr. R to make the caps) took a little more than four hours. At the end of this appointment, the doctor told me he wouldn’t be charging me for filling the teeth on the bottom, and that I only owed an additional $2800 after the $2100 I had already paid.

The doctor assured me that if I couldn’t pay the balance for a few months it would be just fine (even though he knew I was leaving the country in a little over a week). This was actually under the amount I had saved and I was shocked to have anything left over.

 

I had almost a week before my next appointment for the bottom teeth, and the following day would be when the porcelain caps were scheduled to be put on — just one day before I flew back home to New England. There was swelling in my gums that subsided over time and my discomfort mostly waned. I couldn’t drink alcohol, but I had lots of gelato.

 

One of the smaller things the dentist tried to help me was related to a dog attack I suffered late 2017 (I work in the pet industry), as they noticed a tooth was constantly rubbing against some scar tissue on the inside of my lip. Dr. R offered to elect to reshape/contour the tooth slightly, which would reduce its rubbing on the scarred area of my inner lip. This procedure regularly costs $50-$300 per tooth in the U.S.; I was not charged anything more than we had previously agreed.

At first, it was much more comfortable not rubbing against the scars but as the days went on it became more and more sensitive. By the weekend I could barely breathe through my mouth without the pain in the sensitive tooth becoming unbearable.

The following appointment consisted of a cleaning and five fillings, including the one that was now sensitive. This was probably the most uncomfortable of the appointments for me, as I have always had a resistance to novocaine, though it only lasted an hour. I spent the rest of the evening resting after taking a prescription dose of ibuprofen.

 

My last appointment was the next morning for my permanent caps. The appointment lasted two hours, during which three bridges with the seven crowns were put in. Other than some soreness in my gums, it was the best they had felt in a long time. Everything looked and felt good on my return trip; it was the first time I can remember being able to chew on both sides of my mouth pain-free.

 

If I were trying to get comparable work done in my home country of the United States, I would have to be prepared to spend at least $20,000-$25,000 — easily more. I spent under $5000 in Mexico; a little more when you factor in airfare and the costs of living in a foreign country for almost two weeks. I spent a total of 12 hours in a dentist chair. I was not charged for any x-rays, prescription medications, or any office visit fees.

It is undeniable that I saved thousands of dollars on my dental care, but also that I am fortunate enough to be able to afford even this. Countless Americans need the kind of dental work that I did, and are not fortunate enough to have family abroad or be able to afford hundreds of dollars in airfare alone.

 

I cannot speak to the practices of other dentists in Mexico — I imagine Dr. R was very generous with his services and I wouldn’t know if not charging for x-rays or medications is common practice. Based on my experience, and lacking any overhauls of the U.S. healthcare system, I would likely go back to Mexico for any further dental work I may need.

 

NeedyMeds does not have any information about resources that help patients access healthcare outside of the U.S. or its territories, nor do we endorse medical tourism — anyone considering traveling abroad for medical care of any kind should carefully investigate the care provider and/or the hospital providing the healthcare services — but we do have information on free/low-cost clinics and assistance programs that help with the costs of prescriptions and healthcare throughout the United States and its territories. Visit needymeds.org or call our toll-free helpline at 1-800-503-6897.

For those considering seeking healthcare outside of the United States, Joint Commission International (JCI) accredits hospitals, clinics, and other healthcare providers around the world and is considered the gold standard in global healthcare.

Social Justice & Healthcare

Today is World Day of Social Justice, when we promote efforts to tackle issues such as poverty, exclusion, and unemployment.

Social justice is the concept that all individuals deserve equal rights and opportunities — including the right to health. Even in 2019, inequities remain in healthcare that are avoidable, unnecessary, and unjust. These inequities are the result of established policies and practices that maintain an unequal concentration of money, power, resources, and perceived value within society among communities based on gender, age, race, ethnicity, religion, culture, country of origin, or disability.

 

Racism, homophobia/transphobia, and misogyny are all insidious forms of bigotry that have long-reaching effects into healthcare. Over 30% of medical expenses faced by communities of color can be associated with health inequities, and are more likely to be affected by conditions such as diabetes, heart disease, and cancer. Lesbian, gay, bisexual, and transgender/gender non-conforming individuals often report avoiding seeking out medical care or refrain from “coming out” to their healthcare provider. Women can face difficulty accessing health care depending on where in the country they are, being believed or taken seriously by healthcare professionals, can have their bodily autonomy questioned when seeking certain services, and report forgoing healthcare services more than men.

Studies have shown that healthcare professionals may harbor unconscious prejudice towards certain groups, leading to poorer communication and lower quality of care. Discrimination and implicit bias against individuals has been associated with higher rates of psychiatric disorders, substance abuse, and suicide. Experiences of violence and victimization are frequent for people of color, LGBT people, and women and can have long-lasting effects on individuals and their community. Negative experiences with healthcare providers can also discourage those in need from seeking help in the future.

 

For many, being excluded from access to affordable healthcare can be a barrier in itself to getting a job and escaping poverty. Homeless individuals face significant barriers when trying to access healthcare, and are at high risk for pneumonia, infections, symptoms from exposure, mental illness, and substance abuse. Lack of affordable healthcare on its own can contribute to homelessness. For families and individuals who struggle to pay rent, a serious illness or disability can lead to a downward spiral into homelessness; one could lose their job due to inability to work, deplete their savings to pay for healthcare, and eventually be evicted from their homes with reduced or no income.

Immigrants face particular health concerns, yet access healthcare services less than individuals born in the United States. This could partly stem from the changing policy that could allow immigrants that access public benefits to be deported. Undocumented immigrant children who have been separated from their parents/families under the Trump administration’s “zero tolerance” policy face an increased risk of profound physical and emotional health problems. Thousands of children have been ripped away from their parents with little to no method or plan to ever reunite many of the families.

 

NeedyMeds’ mission is educate and empower patients in need, with a vision of affordable healthcare for all. Our mission is tied inextricably to social justice and the endeavor of abolishing inequalities.

NeedyMeds has almost 100 disease-specific resource sites for many conditions — Diagnosis Information Pages — including those that disproportionately affect people of color. Our website has a database of over 17,000 free, low cost, or sliding scale clinics, more than 6000 of which offer women’s health services including almost 500 Planned Parenthood locations. Search your ZIP code for clinics in your area, and find Women’s Health in Services under the Details heading to find free or low-cost medical attention. There are also nearly 6000 free/low-cost clinics listed that offer mental health services. NeedyMeds has a growing list of programs in our Diagnosis-Based Assistance database for transgender/gender non-conforming people that offer various forms of assistance such as financial aid or legal services to LGBT individuals who experience barriers in accessing healthcare. The free NeedyMeds Drug Discount Card can be used by anyone to help save money on their prescribed medication — even over-the-counter medicine — regardless of immigration status. The card is available physically via mail, in a printable form, or the as a smartphone app for Apple and Android devices. For more help finding information, call our toll-free helpline Monday-Friday 9am-5pm Eastern Time at 1-800-503-6897.

Online Health Information: Not Always Doctor-Approved

“Can Parasitic Worms Cure Seasonal Allergies?”

“New Study Shows Too Much of This Breakfast Staple Will Literally Kill You”

“Here’s Why Sitting is Worse for Your Health than Smoking”

You  — or someone you know — is bound to see headlines like these every day. After all, looking up health information remains one of the most popular internet activities. But as the saying goes, you can’t believe everything you read.

Kelly McBride, vice president of the Poynter Institute, last year told The Atlantic that “of all the categories of fake news, health news is the worst. There’s more bad health news out there than there is in any other category.”

A newspaper advertisement for false "cancer-curing" claims

There’s no such thing as a miracle cure. Photo by Wellcome Library, London, via Wikimedia Commons

Whether it’s viral stories that dandelion weed cures cancer, bogus health advice falsely attributed to the Mayo Clinic, advertisements masquerading as news, or outright fake medical news, scammers have found all sorts of new hacks to earn clicks and trick readers with sensationalized content.

Below I want to dive deeper into two recent examples of popular health stories that misrepresent the underlying science. I’ll point out where they went wrong, then leave you with some tricks of your own to help you weed the bad information from the good.

Example 1: Can taking hormones cut belly fat?

Last March, CNN and other news outlets reported that taking hormones significantly reduces belly fat in postmenopausal women ages 50-80. The story was based on a study published in the Journal of Clinical Endocrinology and Metabolism.

Little did readers know the story had misrepresented the original study’s findings — a not uncommon problem. Journalists failed to mention that the “significant” fat loss amounted to just two ounces.

Close-up of a woman's waist with measuring tape around it.

Weight-loss headlines are popular but often misleading.
Photo by Matt Madd, via Costculator

Worse, there was no mention of the negative side effects of hormone treatment like bloating, breast tenderness, mood changes, and nausea.

Are these side effects worth the small losses in body fat? For many people, they aren’t. But you’d never know from the headlines.

Example 2: Is fluoridated water bad?

Harder to spot are groups using poor science to support their beliefs.

Based on a recent article in Environmental International, ScienceDaily reported that higher levels of fluoride exposure during pregnancy will increase the odds that their children will have attention deficit/hyperactivity disorder (ADHD). The anti-fluoride crowd claims that this is yet more proof that putting fluoride in drinking water is harmful.

A U.S. Air Force service member pours herself a glass of tap water from a sink faucet

Water fluoridation is a popular boogeyman among conspiracy theorists.
Photo by Airman st Class Alexxis Pons Abascal, via Cannon Air Force Base

Unlike the hormone therapy example, it was the original study’s authors who inflated the merit of their results. The study was not done well enough to support their claimanother common problem. The most obvious flaw was that, despite saying that higher intake from fluoridated water resulted in a higher risk of ADHD, the fluoride intake of the women was not known.

I certainly wouldn’t switch pregnant women to bottled water based on this study.

How to spot a fake health news article

Read more than the headline

Remember that news sites are trying to attract readers, so they are more likely to cover eye-catching topics. When reporting research studies, that often means news outlets look to scoop stories on groundbreaking studies that have yet to be confirmed, or less reliable observational studies promoting inflated conclusions.

A “clickbait” headline lures you in but fails to deliver promises. Unfortunately, these are all too common in health news reporting.

Close-up of a hand clicking a computer mouse.

Beware the clickbait headline!
Photo by Marvin Tolentino, via Unsplash

So if a headline grabs your interest and it may apply to you or someone you know, be sure to read the whole article. Look for details within that support the sensational headline.

For example, the ScienceDaily article above reports that fluoride intake was estimated by measuring fluoride levels in urine that had been stored for up to 12 years! That is quite a stretch, and reason to be skeptical of the findings.

Look for indicators of trust

How do you know if you can trust what you’re reading?

Make sure the news site is reputable and clearly lists the author of the news report, along with their experience. Articles written by a science or health reporter trained to understand medical findings are most likely to get and report the gist of the study. It is also important to know about the editors responsible for the content and owners of the website.     

Do a little digging to see if the journal and author(s) have a good reputation and whether or not the article has been peer-reviewed by specialists. Reputable journals are usually published or sponsored by a scholarly society, professional association, or university academic department.

A man stands apart at a rally holding a handmade sign that reads "In Peer Review We Trust."

Who doesn’t love a good peer review?
Photo by Sarahmirk, via Wikimedia Commons

A handy list of peer-reviewed journals can be found at OMICS International.

Find out what other outlets are saying

Sometimes a supporting or more detailed news report can be found on other credible news services. In the case of the CNN headline, MedPage Today provided crucial details showing the small change in stomach fat that CNN failed to report.

Exploring more than one source is especially important for groundbreaking news. If it’s truly important, many news outlets will be reporting it.

A banner, attached to a stick, that reads "Explore."

Explore what other news outlets are saying.
Photo by Andrew Neel, via Unsplash

Another strategy is to search for news reports about studies looking at the same issue so that you can compare.

It is not uncommon for news reports to disagree, even if they are reporting the same research. In fact, controversy and diverse opinions are usually a sign that the reporter has done their homework.  

Additional commentary about the article by expert medical professionals or organizations can also improve credibility. An added benefit may be to increase how well you understand the news report.

Make sure the research is reliable

You definitely want to be reading news based on good research. But knowing what constitutes “good” research can be tricky, especially if you don’t have a background in science. Here are just a few clues that the research is relevant to you:

  • the study in question was done on humans, not animals
  • the benefit to patients is not too small to offset complications and side effects (e.g. the CNN fat-loss article)
  • the treatment is something people can actually do or afford. For example, most people can’t move to Arizona to relieve allergy symptoms
Close-up of a black mouse being held by a person in white lab gear and purple latex gloves.

Studies on mice are not the same as studies on humans.
Photo by Understanding Animal Research, via Wikimedia Commons

Be wary of industry-sponsored trials, such as pharmaceutical or medical device companies, as they are more likely to be biased and show positive results. For example, the study about hormones and belly fat was partially funded by a pharmaceutical company that makes these hormones.

Also be wary if the authors don’t mention the flaws in their study. If they do, those should also be presented in the news report.

Avoid these common signs of fake health news

  • The site or news article endorses specific treatments, products, or caregivers
  • There are links to an online store selling these items
  • The news article only quotes people who agree with the conclusion
  • Only positive research results or specific points of view are discussed.
  • A cause is being advocated
  • It sounds too good to be true, because unfortunately there are few quick fixes and no miracle cures

Final word

So whether you’re reading medical news articles for general interest or because you want to be better informed about your healthcare, you can use these suggestions to help you get more out of them without being fooled.

Since you will likely not be able to evaluate articles like a medical professional, try not to make any rash decisions based on a news report. Before doing anything you should always discuss any “breakthrough” that directly concerns your medical care with your provider.

How to Choose Between an ER, Urgent Care and Retail Clinic

This blog post originally appeared on Zaggocare.org

When you or a loved one is sick or injured, where should you go for medical care? Your primary care doctor? The emergency room (ER)? A retail clinic at your local pharmacy or big box store or an urgent care center? With so many options for care, it can be hard to know which is the best choice in your given circumstances. How should you choose between an ER, urgent care and retail clinic? Read on to learn what factors to consider when you or a loved one need care.

Should you go to the emergency room?

I think most of us know that in a real emergency, such as a suspected heart attack or stroke, or a bad accident, the emergency room is the place to be.  But what about illnesses and accidents that don’t seem life-threatening? Should you go the ER? Maybe not.

Interestingly, one review found that only 40% of recent patients who visited the ER had a major health problem. The review found that patients visited the ER for a variety of reasons, including difficulty getting an appointment elsewhere, thinking/knowing other facilities were not open, or feeling it was the only facility that could treat them.

The advantages of the ER.
ERs have the skilled doctors and nurses, and the equipment, to handle serious illnesses and injuries.

Disadvantages of the ER.
A trip to the ER is expensive, time-consuming, and can lead to unnecessary tests and procedures.

The scoop on urgent care centers.

Urgent care centers are free-standing facilities that can treat patients with pressing, but non-life-threatening conditions. These centers usually have a medical doctor present, and often have labs and x-ray equipment on-site. Therefore, they can often handle minor emergency care that in the past required patients to go to an ER. Some of these centers can even handle minor surgical procedures.

When should you go to an urgent care center?
Conditions suited for urgent care centers include, but are not limited to:

  • Accidents and falls
  • Bleeding/cuts—not bleeding a lot but requiring stitches
  • Breathing difficulties (i.e. mild to moderate asthma)
  • Diagnostic services, including X-rays and laboratory tests
  • Eye irritation and redness
  • Fever or flu
  • Minor broken bones and fractures (i.e. fingers, toes)
  • Moderate back problems
  • Severe sore throat or cough
  • Skin rashes and infections
  • Sprains and strains
  • Urinary tract infections
  • Vomiting, diarrhea or dehydration


Can you use urgent care centers for emergencies?
During an emergency health situation, it might be hard to decide if you should go to an urgent care center or an ER. Consider this general guideline: if you would feel comfortable seeing your primary care doctor for your emergency health issue, then you can go to an urgent care center. If not, go to the ER.

What are the advantages of urgent care centers?
There are many advantages of using an urgent care center instead of your primary care doctor:

  • The clinics usually have extended hours, including nights and weekends.
  • You don’t need an appointment.
  • The large number of clinics can make it more convenient to get to than getting to your doctor’s office.
  • As compared to ERs, you’re likely to see a doctor more quickly, for less money, at an urgent care center. But there may be unexpected expenses – see below for more information.


The disadvantages of urgent care centers.
There is no continuity of care at these centers, which is critical for those managing chronic or serious illnesses. The staff treating you will not know you or your medical history.

You might get a bill with an unexpected fee.
Many urgent care centers are owned by hospitals, which can lead to a surprising and expensive addition to your bill – a “hospital fee”. According to a Boston Globe article, hospitals across the country are commonly charging hospital fees for patients seen at their urgent care centers. The problem is, most patients don’t realize this before they receive care. These hospital fees can be several hundred dollars, in addition to the bill for the doctor, nurse practitioner, lab tests, etc. If you have insurance that requires you to pay a flat fee for urgent care visits, you can still receive a bill for several hundred dollars for the hospital fees. Your insurance company may pay a portion of this fee, but most likely you’ll have to pay a portion out of you own pocket.

What can you do? If you plan on using a hospital owned urgent care center, ask about their fees. The information should be available on their websites, or you can call and ask. And a call to your insurance company to determine what portion of this fee will be covered is a good idea as well. If you live in an area with several urgent care centers, I suggest you investigate the fees before you need services. You’ll save yourself time and money.

What about retail health clinics?
Retail health clinics are located within retail stores, such as pharmacies and big box stores. Retail clinics are staffed by nurse practitioners and physician assistants, with no doctor present. They are not designed to address pressing issues. Instead, they are geared towards smaller health needs that patients can deal with at their convenience.

You may worry about the quality of care, but studies show that patients with low-acuity problems receive the same caliber of care, if not better, as compared to going to the doctor’s office.

When should you go to a retail health clinic?
Retail health clinics are great for:

  • Immunizations, such as the flu shot and shingles vaccine.
  • Minor, uncomplicated illnesses, such as fevers, colds, sore throats, rashes and scrapes.


What are the advantages of retail health clinics?
There are many advantages of using a retail health clinic instead of seeing your primary care doctor, including:

  • These clinics are open 7 days a week, including nights.
  • Employees at retail clinics often do a better job at following care guidelines than doctors.
  • In general, the nurse practitioner and/or physician assistant spends more time with patients (as compared to a doctor’s office), which can improve the experience for the patient.

The disadvantages of retail health clinics.
As with urgent care clinics, there is no continuity of care at retail health clinics.

Retail clinics might be too convenient.
Since it is so easy to get care at a retail health clinic, patients are getting medical care instead of “toughing it out” at home. RAND Corporation found that most visits (almost 60%) were for routine medical care that patients otherwise would not have sought – leading to an overall increase in the use of medical services.

Many patients choose the wrong option.
Many patients don’t understand the different levels of care between retail clinics, urgent care centers and emergency rooms, often leading patients to make the wrong choice, which can waste time and money. And cause frustration.

According to a 2017 CityMD survey, many don’t make the right choice when deciding between an emergency room or an urgent care center. The survey presented 8 health scenarios in which the patient wanted immediate care. The 2,000+ US adult respondents were asked if an ER or urgent care center was the best option for care in each scenario. Most respondents clearly understood the need to go to an ER for life-threatening health issues. However, many respondents wrongly chose the ER for many cases that could be treated at an urgent care center.

Talk to your primary care doctor about your options.
Ask your doctor now about the best options for you (and your family). Don’t wait until you are sick or injured to figure out where to go for care.

  • If you are dealing with a chronic or serious illness, ask your doctor if it’s okay to use a retail clinic or urgent care center, and find out what circumstances would warrant a trip to an ER. Ask your doctor where to get care for disease-related symptoms or minor colds or injuries.
  • Find out what conditions don’t require immediate attention, instead taking a “wait and see” approach.
  • Ask your doctor if he/she has a relationship with a particular retail clinic or urgent care center – and if so, use these whenever possible.


Follow up is key!
Researchers found that medical providers are not following up on tests conducted in the emergency room between 1% – 75% of the time. Clearly, this lack of follow up can lead to serious health consequences, including missed or delayed diagnosis and even death.

Don’t let your health skip through the cracks. If you don’t get your test results before you leave the ER, urgent care center or retail clinic, find out how to get the results. Get the name and phone number of a person to call and find out when the results will be available. Mark your calendar so you won’t forget. Do not assume someone will reach out to you if the results indicate further care or testing is needed.  In one study almost 30% of primary care doctors reported they personally missed abnormal test result alerts that led to delays in patient care.

Additionally, if you go to a retail clinic, urgent care center or ER, always ask the staff to forward the appointment information to your doctor(s). Since your doctors may not see this report, get a printed visit report and share it with each of your doctors. Furthermore, it’s always a good idea to let your primary care doctor know you were treated elsewhere. Not only can your doctor add the information to your record, he/she may recommend further testing or care.

 

About Zaggo:
Roberta Carson started Zaggo, a non-profit organization to help patients and family caregivers manage illnesses and injuries, after her experience as caregiver for her teenage son Zachary during his 27-month battle with terminal brain cancer. Roberta realized patients and families urgently need practical, easy-to-use information and tools. Zaggo’s mission is to provide patients and families with the educational information, tools, and resources they need to become empowered, engaged, effective members of their medical teams for the best possible care. With an easy-to-use guide book and organizational tools, the ZaggoCare System is the only product to offer the comprehensive advice and tools needed to help patients and caregivers manage illness or injury. As a charitable organization, 100% of the profits from the sale of ZaggoCare are donated to innovative brain tumor research in memory of Zachary.

The Donut Hole is Closed!

The year 2019 is here, and there is some good news to those who have had experience with the Medicare Part D “donut hole.” Since the passage of the Affordable Care Act in 2010, the “donut hole” has been on track to close by 2020. Due to the passing of the Bipartisan Budget Act of 2018, which stopped last year’s nine-hour shutdown of the federal government, the Part D “donut hole” has actually closed a year ahead of schedule.

Photo by Patrick Fore

Medicare, one of the publicly funded health insurance programs for people over 65 or people younger than 65 with a qualifying health condition, is divided into four parts. This can be confusing for those who are newly eligible trying to find what the differences are and what benefits they will end up having.

 

Medicare Part A is hospital insurance. This part of Medicare provides you a place to stay with meals while you receive medical services whether at a hospital, hospice, or skilled nursing facility.

Medicare Part B is for medically necessary outpatient procedures. This covers a portion of doctor office visits, lab testing, diagnostic imaging, preventive care, surgeries, ambulance rides, chemotherapy and radiation, and even extensive dialysis care for people with renal failure.

Medicare Part C, also known as Medicare Advantage, is private plans that can be purchased in place of Medicare. Patients can get their Part A, Part B, and sometimes also Part D all from one insurance carrier. Advantage plans usually has a network of providers from whom you will be able to seek your care. Part C plans can often have lower premiums, but patients pay more copays as you go along so they are not necessarily cheaper over the long term.

Medicare Part D covers prescription medications. Unlike Parts A and B, patients do not enroll for Part D through Social Security but instead select an optional plan that are offered through private insurance companies.

Basic Medicare Part D coverage works like this:

  • You pay out-of-pocket for monthly Part D premiums.
  • You pay 100% of your drug costs until you reach the $415 deductible amount.
  • After reaching the deductible, you pay 25% of the cost of your drugs, while the Part D plan pays the rest, until the total you and your plan spend on your drugs reaches $3820.
  • In the past, once you reach this limit you would hit the coverage gap or “donut hole.” You are now responsible for the full cost of your drugs until the total spent reaches the yearly out-of-pocket spending limit of $5100.
  • After this yearly spending limit, those covered by Part D are only responsible for a small amount of the cost, usually 5% of the cost of their drugs.

 

The gap in prescription drug coverage under Medicare Part D has been referred to as the “donut hole.” In 2019, once you reach $3820 in prescription drug costs (which include both your share of covered drugs and the amount paid by your insurance), you will be in the “donut hole” coverage gap.

Starting this year, the “donut hole” has closed so much that those covered will get the same 75% discount on brand-name drugs and a slightly lower 63% discount on generic prescription drugs while you are in the coverage gap. When your total out-of-pocket costs reach $5100, you qualify for “catastrophic” coverage. At that point, you are responsible for only 5% of your prescription drug costs for the remainder of the year.

 

The closure of the “donut hole” is a relief to those who have lived in the gap who were often unable to afford their medications. For those looking for more information about Medicare, each state in the U.S. has a State Health Insurance Program (SHIP) that provides free one-on-one telephone counseling and advice services, personal face-to-face counseling sessions, public education programs and media presentations. Most SHIP counselors are volunteers who have received extensive training and are well versed with all facets of the Medicare program, including Part D. NeedyMeds has a directory of all SHIP sites.