McCamy Taylor's Journal
Member since: Tue Nov 9, 2004, 06:05 PM
Number of posts: 14,577
Number of posts: 14,577
Here is my fiction website: http://home.earthlink.net/~mccamytaylor/ My political cartoon site: http://www.grandtheftelectionohio.com/
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Serious question. In this month's Texas Medical Association magazine, there is an article in which they warn providers that there is no way to know that a patient is actually covered by ACA insurance due to the premium payment grace period loophole. When the doctor and hospital call for eligibility, the insurer will say "Yeah, he is covered." The insurance is not required to mention that the patient is late with his last payment. The problem comes if the patient decides not to make last month's premium payment of $100 bucks after the surgery. If he never makes that payment, the health plan can then go back to the doctor and hospital and demand that all of its money be refunded. But before they take back the money they have to warn you "Your patient has not made a payment. Time is running out." If this happens, the article warns, doctors and hospitals are advised NOT to make the premium payment for the patient, at least that is the recommendation of the CMS.
Why not? What happens if you pay the $100 bucks for the insurance so that you get to keep the $5000 that you earned?
That is not a rhetorical question. CMS has said "Don't do it." Why not? Do you get hauled into court, charged with committing some kind of fraud? I.e "The patient only stayed in the hospital and had the life saving appendectomy because the hospital agreed to pay his $100 insurance premium. Had they not agreed to pay that premium, he obviously would have walked out the door and died." Yes, it sounds stupid. But replace "appendectomy" with something elective like "chiropractic manipulation" and maybe the insurance company has a case. According to Medicare, failure to do something as simple as charge a patient a copayment is "fraud" designed to drum up business and bilk the government out of money.
Lots of rural areas can not keep doctors or hospitals, because their poor and/or self employed residents do not have health insurance. In the 24 states that did not take the Medicaid expansion, rural areas are in big trouble. Is there any law that would prevent a rural county in Texas from coming up with the money to pay the additional premiums to buy all of its poor and uninsured citizens silver or even gold insurance under the Affordable Care Act?
How about large urban areas, like Dallas County, which often spend a lot of money running public health clinics for the uninsured? Could they legally pay the patient's portion of the insurance premiums for a private insurer?
Parkland is considering paying the Affordable Care Act insurance exchange premiums for some of its patients, a move that would help stem the tide of uncompensated care, WFAA reports.
Can Parkland in Dallas, which serves a huge population of sick lower income workers legally dip into its deep pockets and pay the premiums of its working patients who qualify for ACA so that it can then bill their ACA insurer for the care they receive at Parkland Hospital and its clinics? Keep in mind that a Parkland patient is not your typical patient. Your Parkland patient is the one that used to be called "uninsurable"--lupus, sickle cell, cancer, renal failure, heart failure--you name it. The privates hope that lack of money---i.e. the poverty that accompanies being chronically ill---will keep these folks off their plans in states that did not take the Medicaid expansion. They hope that they will be stuck on the so called "bronze" plans with high deductibles and no participating providers in their part of town and no drug coverage--so they never use their new insurance, they will just keep getting uncompensated care at their local Parkland. So, what happens if Parkland tells Blue Cross, Blue Shield "Here's your $50,000 check for this month's premiums for our 1000 patients who have you ACA insurance---and here's your bill for their $500,000 in care"?
We know that a third party without a financial concern can make the payments. And we know that insurers do not want any third parties making anyone's payments.
Three Louisiana health insurance companies have agreed to continue accepting federally-funded third-party payments for premiums, according to a statement from the LGBT group Lambda Legal, which with the New Orleans AIDS Task Force filed a federal class action discrimination lawsuit against the insurers.
Insurance plans will only make a profit under the ACA if the number of healthy people signing up outweighs the number of chronically ill people. In the United States, "Sick and Poor" is something you hear a lot, because illness and poverty go hand in hand. If you are too sick to work, you are poor. If you are poor, you can not well. That $50 to $150 means tested monthly premium may be all that stands between a private health insurer and bankruptcy---and it may be all the stands between life and death for one chronically ill individual.
Which matters more? The health of the health insurance industry that makes up the backbone of the ACA or the healths of the individual men and women whom the ACA is here to serve? Note: there is no answer to this one. It's just here to make us think. Life is full of hard choices.
Posted by McCamy Taylor | Mon Apr 14, 2014, 07:18 PM (6 replies)
I have known Opal for five years. In that time, her health has gone from not too good to pretty bad, but she is hanging in there. Or rather, she was hanging in there. I am a family physician at a county clinic for the uninsured in Texas, one of the 24 states that refused the Medicaid expansion. Our governor did everything he could to make the ACA rollout a failure. But nevertheless, Opal’s husband works, and he makes just enough to qualify for care under the Affordable Care Act. Great, right? Having some insurance is always better than having no insurance, right?
Like many urban areas, my county funds a public clinic for the uninsured. We pay for necessary medications, surgeries. We do screening colonoscopies. We do mammograms and immunizations. If you have a heart attack, you can get your coronary artery stented. If you get cancer, you can get your chemo. No deductible, no caps, no pre-existing conditions exclusions and while there are some medication copayments, you can get them waived. We don’t want to see anyone die for lack of $5.
The Medicaid expansion would have taken over the cost of running the clinic. Since Rick Perry thinks he has a shot at becoming Vice President, he said “No” to billions of dollars. Therefore, taxpayers in our states urban areas will continue to face double taxation---once to pay for health care for our own poor, once to pay for health care for the poor in the lucky 26 states that took the expansion. Tax payers in rural areas will continue to see their hospitals close and their doctors flee----but this is not about them. This is about Opal.
The county was told that the ACA’s so called “bronze plan” would allow its members to keep seeing their county doctors and getting the care they are used to receiving through the county. Opal and her husband were told the same thing. They were relieved. The bronze plan only cost them pennies a month out of pocket. The next cheapest plan would have cost them $100 a month---and people who live with chronic illness don’t have that much cash lying around. Once they signed on the dotted line. Opal and her husband---and the county—learned the truth. Opal now had insurance that had an enormous deductible. Her insurance would cover care only if it was prescribed by a tiny handful of providers---anyone who believes that HMO provider directories are accurate has obviously never dealt with an HMO. Anyone who believes that the people who sign you up for an HMO tell the truth has never encountered an HMO rep.
Opal needed her medication. Her medication cost $500. Opal did not have $500. Opal had not met her deductible. Her $5000 deductible. Opal had a heart attack. Opal went back to the county hospital. She is getting care again with her county doctors. Too bad it was that last little bit of her heart that she could not afford to lose. I wish you could hear the fluid in Opal’s lungs when she breathes. I wish you could see the fear in her eyes as she faces her mortality.
You can make some things right, after they get messed up, but you can’t put back dead myocardium or restore a dead kidney or replace infarcted brain. Yes, I love my party. Yes, I want to see it do well in the elections this fall and in 2016. But I am not going to keep my mouth shut and watch Opal and people like her get sick and die, because the ACA has as many holes in it as the god damned Titanic, and the GOP and the SCOTUS and the Tea Party is exploiting every last one of them.
So, if you want to go back to circling the wagons around the ACA, insisting that everything is just fine, go right ahead. You can even accuse me of not being a Family Physician and of not working with the chronically ill and uninsured. But if you try to accuse me of being a Bad Democrat, of not supporting the President, because I won’t keep my mouth shut, I have to ask:
What kind of Democrat would ask another Democrat to keep quiet about the suffering of the chronically ill? No Democrat, that’s who. The only folks who hate the chronically ill are the bean counters of the private health insurance industry. And they will do whatever it takes to make sure that those who make the mistake of signing up for their “bronze” plans get the hell back off---assuming that they don’t die first.
And that is no exaggeration. Though Opal’s name has been changed, for reasons of patient confidentiality. The fluid filled lungs, her fear, my anger---they are all real.
Posted by McCamy Taylor | Sun Apr 13, 2014, 11:28 PM (141 replies)
SUPER LONG Thread Warning: Enter at your own risk. If you have Fidgets Disease, be sure to take your medication first.
Before you start reading this, this is not a medical literature review of the pros and cons of any specific treatment for Hepatitis C. This is a study about how Things Are Done in the United States by Private Pharmaceutical Companies and Public Health Departments and Elected and Selected Political Leaders that have the potential to make a very few, very lucky people even richer than they already are. This is a medical economic case study of the Medical Industrial Complex. I am not alleging any illegal activities or ungodly conspiracies. Everything I am about to describe is 100% business as usual in the land of Greatest Health Care System in the World. Anyone looking for a conspiracy theory, move along. You don't have to break the law in order to make it rich in a land where Citizens United is the law.
Those who follow Big Pharm know that Former Bush Defense Secretary Donald Rumsfeld is a very savvy businessman. No, I am not talking about the petrochemical industry or the Military Industrial Complex. The Iraq War did not turn a profit for either Chevron or Halliburton, not when you consider the cost in dollars and lives to the people of the United States and Iraq. Corporate Welfare would have been much cheaper and more compassionate.
Rummie knows how to make a buck from the Medical Industrial Complex. He owned a lot of stock in Gilead which owns Tamiflu, which the US government stockpiled in 2005 under orders from W. during the scare over the possibility of a pandemic and which has become a mainstay of medical treatment for the various swine flu epidemics that have ravaged this country since 2009. Rummie's Gilead stock made him a very rich man.
Well, Gilead is about to strike it even richer. That is because in 2011, it acquired Pharmasset Inc., a company that makes, among other things, a new Hepatitis C medication, Sofosbuvir, which will be available in an easy to take one pill a day for eight weeks form (no more injections, yeah!). Supposedly, the cure rate with this one will be close to 100%. Supposedly, there will be fewer side effects. Definitely, it will require a 2nd and 3rd home mortgage to afford, because it is priced at a whopping $1000 a pill.
I can hear you through the ether-net. The manufacturer has to recoup the research cost. A thousand dollars a day is not too much to prevent my liver cancer. Thank God I just signed up for my new ACA Insurance/got my new Medicaid card. Thank God my doctor just tested me for Hep C. Oh, wait. I haven’t been in for a checkup yet. I’ll be sure to ask for a test. The Republicans might repeal the ACA.
This is not just about the cost of the pill. This is about some other things that have happened since Gilead acquired Sofosbuvir in 2011. Two other things to be precise.
First, in 2012, the CDC proposed that all Baby Boomers (born between 1945 and 1965) be screened for Hepatitis C. If you saw a doctor in 2013 for a routine checkup, you very likely had a Hepatitis C test done. And a few of you were surprised when it came back positive. Hepatitis C was not on your radar of things to worry about. Some of you probably were not even asked if you wanted it done. Your doctor talked to you, told you not to worry, your liver tests were normal. “And, in any case, there is a new, safe, effective treatment coming out.”
If you are lucky enough to live in one of the 26 states that took the Medicaid expansion, meaning that all its citizens have access to health insurance, you just got your Affordable Care Act insurance or your Medicaid this year. A Hepatitis C test is likely to be one of the things your new doctor orders, if you were born between 1945 and 1965. Your doctor is required to order it. Or at least ask you if you want the test done. It is now part of the recommended panel of health screens. And, if the test comes out positive, you will go online and look it up. You will be relieved to see that there are new drugs that the FDA claims are effective and safe. You will be dismayed when you see the price tag---$1000 a pill—but hey, that is what insurance is for, right? Which brings me to my Second point. Gilead’s new drug will be rolled out right as millions of Baby Boomers 1) get insured and 2) find out that they have Hepatitis C.
Now that is good planning. That is how you become a success in Big Pharm today. You identify your target, you create a demand, and you make sure that your target has someone else it can demand pay your exorbitant rate because no individual in his right mind is going to pay $1000 a pill for something that is not even bothering him, but if he can get it for “free” from his insurer or the government then “What the hell? Why not?” And the more asymptomatic, healthy individuals you treat with your drug, the better its profile will be and the lower the rate of bad outcomes will be.
Hint for people in the 24 states that did not take the Medicaid expansion. If you want the drug and you have no insurance, most drug companies have a compassionate use program that allows needy folks to get their drugs for free. Let’s see how compassionate Former Defense Secretary Rumsfeld’s old pharmaceutical company is.
Everyone else, be prepared for some hardball as insurance companies and those who manage public health care dollars wrestle with Gilead over sums of money that have the potential to bankrupt some healthcare plans. Not kidding. There are an estimated 15 million Americans with Hepatitis C (2/3 don’t know it yet). If we treat them all, that is $15 billion a day for 8 weeks. That is getting mighty close to…$2 trillion. And that is just the US market. Then there is Europe. And Japan, where all those poor women were given Hepatitis C tainted products after routine delivery. (see the Bloomberg link below if you have not followed this one) But wait. Japan has approved the competing drug, Simeprevir to treat Hep C. Yes, you read that right. There is competition. Yes, I know that competition is supposed to keep down prices. Imagine how much these drugs would cost if there was not a similar drug being released at the same time. $10,000 a pill? Thank God, Allah, Buddha and the Goddess for the Free Market system!
What about the third world? Gilead’s negotiating the price down in places like India. If they don’t, they knows India will make their own cheap generic. But in the US, Gilead has patent protection and can charge whatever you the taxpayer and insurance policyholder and your attorney think is reasonable. (Not a lawyer, so if I have the next bit wrong would welcome any free legal advice, hint, hint.) For the ERISA loophole---the one that limits damages against a health insurer that denies a treatment to the cost of the denied treatment in the event that something bad happens to you because of the denial of the treatment---probably does not apply to your new ACA insurance, which you are not getting through your employer. So, if your new ACA insurer says “No.” and you die of liver cancer, your new insurer could lose big in court. And Gilead knows it.*
I expect that the $1000 a pill won’t be the final offer. It is a flashy number that was probably chosen because it would generate a lot of media attention. And a new, one a day oral eight week treatment for Hepatitis C can not get too much free publicity right now, with everyone getting new insurance and everyone getting tested for Hepatitis C. I expect Gilead to show some compassion and bring it down to $400-500 a pill. A mere $1 trillion. From the US.
Not to make light of the costs of developing drugs. Forbes estimates that Big Pharm spends $12 billion per drug approved to get a product on the market. But Gilead did not make Sofosbuvir. It bought the company that made it.
Oh, and since no cost is too high to prevent your liver cancer, how about to prevent liver cancer in the guy who is in jail for breaking and entering? How about the guy who allows himself to be sent to jail for possession so that he can get the Hepatitis C treatment he cannot afford on the outside? You’re good with that, too, right?
In case you thought that this was the only Big Drug that is coming down the pipeline, Silly Rabbit, what's sauce for Gilead is sauce for every other pharmaceutical company. Expect a massive onslaught of new drugs that you and your family absolutely can not live without for conditions, some of which you did not even know existed---until now that some drug company is trying to get its piece of our country's annual $3.8 trillion (and growing!) health care spending. And you believed Glenn Beck when he told you to invest in gold. Sigh. I hope we have enough left to pay for vitamins for pregnant women and vaccines for babies once we are finished treating every child with Fidgets Disease and every man with Insufficient Machismo.
*Special plea to any lawyers out there. I know this is a tough one. Did ACA change the way ERISA affects lawsuits against employer sponsored health insurance? Did it expand ERISA? Close the loophole? You know the one I am talking about. The one that says that your Health Insurer can refuse to pay for your heart medication and if you die of a heart attack your family can only sue to get reimbursed for the cost of the pill, not your life. Because I cannot imagine Congress knowingly changing the Health Insurance industry’s favorite loophole, and if it stays the way it is, then once employers start providing more of the coverage then folks going to court to seek relief during disputes with their health insurance will find their options (including their choice of attorneys) limited, since the health insurer will only be responsible for the cost of the treatment, not the cost of the consequence of the missed treatment, including suffering and death.
Oh, look! <----A pumpkin smiley! Hmm. Did I take my pill for Fidgets Disease today?
Posted by McCamy Taylor | Sun Apr 13, 2014, 05:05 PM (1 replies)
"Mommy, what did you do during the 2008 Democratic Presidential Primary War?"
"Uh..I wrote shit online. Mostly about other shit that was being written."
"Because someone had to. It was not the corporate media's finest hour. Not their worst either. That was 2001-3, the "(Oil) Drumbeat to War". Oh, and 2000, "Gore is a Liar". And 2004, "Exit Polls are Reliable in the Ukraine but Not in Ohio." Actually, what passes for a 'free press' in this country has been neither 'free' nor a 'press' in a long time. More like Pravda, if Pravda, represented four or five giant financial consortia rather than one country."
"What's a financial consortia, Mommy?"
"They're the ones who try to pick your party nominee, honey."
"I thought we did that, Mommy."
"Silly, rabbit. What do you think this is? A democracy?"
Read about why you thought Edwards was a Phony and Hillary was a Bitch and Obama was a Scary, Scary Black Muslim in this collection of essays by yours truly from 2007-2008 which I call "Food Fight at a Monster Truck Rally." It's FREE at Amazon for Kindle for the next five days, along with most of my fiction. Your democracy is not free. It takes lots of work.
Posted by McCamy Taylor | Thu Mar 27, 2014, 08:21 AM (2 replies)
Warning! Long thread ahead! Travel at your own risk.
"No looking back on tomorrow...better think on today."
If you choose to read this, please listen to the music at the following link simultaneously. And if you don't want to read this, please listen anyway. This song is about a million times better than what I am about to write.
Peter Hammill performs the song "Flight" from his album Black Box, this is a live solo version, Hammill doing vocals (duh) and accompanying himself on piano. Video is someone's compilation (not live).
Now, on to the topic, which is...
Mammon or muse?
"Mammon and Muse walk into a bar..."
I have been listening to lots of Peter Hammill on You Tube recently. Which raises the question, where is the Peter Hammill Needs Money Police? You know, the folks who spend their time shutting down Internet bootleg? Apparently, Mr, Hammill is too busy writing, recording and performing to do it himself. Good for him. He survived his heart attack. May he live forever---meaning long enough---and keep writing and recording. Praise Gog.
And now, to the---no, not the, a ----as in one of many point(s), which is, how do we juggle the need to create art with the need to eat? This is an extremely loaded topic, right up with there with 1) Religion and 2) Politics on the list of Things Thou Shalt Not Talk About at the Thanksgiving Dinner Table Unless You Want a Food Fight.
I do not want to precipitate any food fights, so I am going to move this discussion to the far side of the Pacific Ocean. In Japan there is another term for mangaka. It is "richer than Croesus." Meaning that the people who create manga make a whole lot of money. Not like the US where DC and Marvel (now Disney) own your characters. That is why so many people create manga. So, consider two of the most successful mangaka, Rumiko Takahashi (Inuyasha) and Takehiko Inoue (Vagabond). It helps if you are familiar with their work. But if you are not, Rumiko's is sort of cutsie, shoujo-shonen-esque with so-so art, Takehiko's tends to be more mature, takes more risks, extremely inspired/technically competent art even by western standards. Now, Takehiko Inoue is on record as saying he does not care who posts his stuff on line and he even posts manga himself for free for fans (Buzzer Beater was an online manga). Rumiko Takahashi, on the other hand, has a rep as not tolerating any form of piracy--and that is saying a lot for a country that does not tolerate piracy. Keep in mind that both of them have more money than they will ever spend.
Where is this all going? The same place we are all going. No where. But, just to pass the time until we get there, I will step out on a limb and hazard a guess. I suspect that when Takehiko Inoue pens another chapter about swordsman Musashi learning universal truths from watching rice grow (Vagabond) or describing the struggles of wheelchair basketball players (REAL), he has a deep sense of personal satisfaction that makes the box office grosses ( I don't know if there is an equivalent term for this for manga) irrelevant. But when Rumiko Takahashi churns out another bit of Inuyasha clone, she is just going through the motions--in which case that royalty check is the carrot. But that could be----no, that probably is just my personal bias.
(And if you are not listening to Peter Hammill perform "Flight" please go click on the link.)
Now, for the counter argument. Think about Alan Moore, probably the most talented English language author alive today now that William Burroughs has gone off to the Western Land. Think about how the Comic Book Industry has used him. Think about Hermann Melville, whose Moby Dick, the greatest American novel of the 19th century was trashed by the British critics---who were not amused by the novel's themes of God-killing which is another form of anti-colonialism---and who therefore died in near obscurity. Think about William Blake, whose poetry was rescued by the merest chance---his Free Love agenda coincided with that of Victorian poet Algernon Swinburne. And no, I am not going to argue for a state subsidy for starving artists and poets. These writers received support----not financial support, moral support. They were and are the "Voice of honest indignation" (to quote Blake) which we so revere---
But you've gotta wonder. Worry and wonder. What Donnes labored and died in the cotton fields of Alabama, their words of beauty and wisdom lost forever, because it was illegal for slaves to learn to read and write? What Yeats are going unheard at this very moment, because they are too poor to afford a computer, and even if they had one, they don't have electricity in their third world hovel? All those rebels with a cause I mentioned above, those were and are all white guys with educations and good health and supportive families. When your life is a plane crash, how do you make yourself heard? What do you do if society does not give you a black box?
Ok, now read the lyrics to Peter Hammill's song that I hope you have listened to at least once or twice by now. But do not read the lyrics unless you have listened to him sing them, because he is a singer-song writer not a poet and the delivery is three parts of the poetry. (In keeping with the four paragraph rule I'll post two stanzas, I urge you to go read the rest yourself, the lyrics are from the album version, the live version is a little different):
It was then that I knew I'd been thoughtless -
What the hell did any of that stuff about mammon and muse and voices of honest indignation have to do with Peter Hammill's 1981 version of a song about a plane crash as a metaphor for life? If we did not have people willing to do art for art's sake, then we would not have so many works of art waiting to touch that nerve that needs to be touched when the proper moment arrives. As we do our forensic investigation, read the tea leaves, examine the entrails and consult the stars for the answers that will keep something like this from ever happening again, I suggest that we also examine ourselves, because if we do not know ourselves we can not hope to know anything. And because life is so very fragile and so very fleeting and because so many people with such beautiful stories were not gifted with beautiful voices, I recommend that we take time to listen and then tell those stories. If every work of art strove to be Grapes of Wrath rather than---say---Twilight---think about what the world might be.
"I can't tell you nothin'. You got to go there." John Steinbeck The Grapes of Wrath
Posted by McCamy Taylor | Sun Mar 23, 2014, 04:15 PM (1 replies)
Yes, this is a scary headline. Almost sounds sensational. It isn't. It is a cold hard fact. At this moment, if you are counting your pennies, trying to scrape up enough to pay for a $4 drug at Wal-Mart or Target, you can not afford an antibiotic that will treat your walking pneumonia---meaning that you could end up in the hospital saddled with tens of thousands of dollars in medical bills.
For years, doxycycline has been a valuable drug for physicians who treat the indigent --- unemployed or underemployed folks without insurance. A staple of $4 drug lists, it can be used to treat everything from bronchitis to "walking" pneumonia to urinary tract infections to skin infections to acne to venereal disease---and it covers some rarer infections like Lyme's and is sometimes used for malaria prevention, too.
For as long as I can remember--and I am pretty damn old---doxycycline, a twice a day form of tetracycline has been widely available and cheap as dirt.
And then, this winter, something surprising and very troubling happened. A patient with a list of medical problems longer than his arm and no income (he was still appealing a Social Security Disability denial) came down with bronchitis, possible early pneumonia--the two can be difficult to differentiate. I wrote him a prescription for doxycycline. He took it to the pharmacy. They wanted over $50 for it. He did not have over $50. He had $4. That was how much the drug used to cost at the same pharmacy.
He is not alone. Here is an LA Times Story about someone who had the same problem last year. Turns out that the difference can depend upon which generic drug manufacturer is making a specific medication at any given time. And apparently, right now, the one making doxycycline charges an arm and a leg for it.
A CVS pharmacist in Los Angeles, who asked that his name by withheld because of fear of retaliation by the company, shared with me the average wholesale price of different makers' doxycycline, as made available to pharmacists by the McKesson Connect online ordering system.
Mylan? Where have I heard that name before? Oh, yes. ALEC. As in "The Koch Brothers" and their corporate welfare mentality.
Where else have I heard of Mylan? Oh yes, the great lorazepam price fixing scandal.
The Federal Trade Commission approved a $100 million settlement with Mylan Laboratories, the largest monetary settlement in the commission’s history.
Mylan is now the third largest generic drug manufacturer in the world since it acquired an Indian generic drug manufacturer--meaning that it is in great shape to corner the market on these all important key ingredients needed for drug manufacturing.
Not so long ago, the nation watched as patent drug manufacturers paid generic drug makers NOT to produce their product---keeping drug prices high. Keep that in mind as you ask yourself why a drug as popular as doxycycline is in short supply. This is not one of those orphan drugs that no one wants to make because almost no one needs it. This stuff sells itself. The more that is made, the more we will see it used. Why isn't supply attempting to keep up with demand? Where is the bottleneck in the so called "free market economy"?
If this were a fictional mystery, I would now tell you why doxycycline has gotten so expensive that poor folks can no longer afford it. Since this is real life, I don't know. If someone out there knows the answer, please tell me. Meanwhile, when a patient without money and without prescription drug coverage comes in which bronchitis/and or pneumonia, I am going to be hard pressed to get him treated with what is currently available on most $4 lists.
Posted by McCamy Taylor | Sun Mar 9, 2014, 05:23 PM (48 replies)
I have blogged before about Managed Medicare abuses. About how a loophole in health care law allows the plans to bill their own internal Q&A as direct patient care. And about the massive number of medication denials which they issue, most of which are designed to create patient and doctor hassles rather than save the insurance plan money.
The latest target: albuterol inhalers, the inhalers that every asthmatic uses for asthma attacks now that all the competitors are gone. That's right. Albuterol is the only drug available in the U.S. for use as a rescue inhaler. There is nothing else that can take its place. And, because of reformulation issues, all of these inhalers are extremely expensive--too costly for a cash strapped senior or disabled person to buy his or her own, no matter how badly he or she is wheezing. So, how did I get not one but three Medicare Managed Care denials for generic albuterol inhalers in one day?
I wanted to know the answer to that one myself. So, once my medical assistant got a representative of the insurance plan on the phone and discovered that while the plan did not cover generic albuterol inhaler, the plan did cover Pro-Air--a name brand albuterol inhaler, I took the phone.
"Why?" I asked the young man at the other end of the line. "Does Medicare Advantage Plan C cover a name brand albuterol inhaler but not a generic albuterol inhaler? Why can't the participating pharmacy substitute Pro-Air for 'generic albuterol inhaler'?"
"This is the doctor. I really want to know why my patients can not get their asthma inhalers when they need them. Why do they have to do without their medication until their doctor can talk to an insurance rep? Can I talk to your supervisor?"
Ten minutes of holding and no supervisor came to the phone. While waiting for the supervisor that never appeared, I looked up the drugs in question. My drug handbook listed all the albuterol inhalers as being interchangeable. I gave up waiting and I called a pharmacist. "Are Pro-Air, Ventolin, Proventil Inhalers and generic albuterol inhalers all the same thing?"
"Yes, they are," said the pharmacist.
"If one was not in stock could you substitute another as long as the prescription did not specify name brand only?"
"Yes, I could."
Very strange indeed. So, basically, my asthmatic patients on Medicare had been forced to do without their rescue inhalers until their insurer could fax my office a worthless piece of paper that my nurse showed to me the next day that I was in the office--meaning potential refill delays of up to 72 hours. How does that keep my patients healthy? It doesn't. Instead, it scares them. Anyone who has asthma knows how bad it feels to need your inhaler and not have one.
In what kind of country is it legal for someone's insurance company to deny them a necessary medication for 72 hours for absolutely no reason? A crazy country. Why would an insurer want to do this? That's easy. Scare your sickest patients enough and they will drop off your Medicare plan and sign up for a different Medicare plan. Since Medicare Advantage plans are paid a flat fee by the federal government for each enrollee, they have an incentive to keep healthy people happy with bicycle socials and sick people scared by denying them their medications. And it is working. People with the biggest burden of chronic illness are the ones most likely to drop off a so called Medicare Advantage Plan and back onto traditional Medicare, meaning that the tax payer picks up their bills while the privates collect premiums--and then pay themselves for denying services and benefits (the Q&A loophole).
This is not an isolated incident and it is not confined to a single Medicare Advantage Plan. See my old diaries for other examples. This fragmented Medicare is ruining the best insurance plan in the country---and, in the process, making it even less likely that we will ever see a single payer insurance plan since the privates can point to the mess they have made of Medicare---siphoning all the money off and leaving all the debt for the public to pay---and say "See? See? Single payer is too expensive."
Posted by McCamy Taylor | Sat Mar 8, 2014, 05:55 PM (32 replies)
In the 19th century, people knew that their water was clean. They could tell by looking at it. Sniffing it. Tasting. Then Louis Pasteur showed them what they could not see, smell or taste---microbes that caused disease. Once we became aware of the danger, we were willing to invest in sanitation services, sewage treatment, water filtration.
In the 21st century, people know that they get a good night's sleep. They go to bed at 11 pm. They set the alarm for 7 am. They lose consciousness for the next eight hours. They wake up feeling tired, achy and groggy, but that is just caffeine withdrawal kicking in. After a cup of java, they are good to go--for a couple of hours. Boy, age sure has crept on them. They sit at a desk all day, but they are always hungry. None of their old clothes fit. When they get home, they don't want to do the dishes. They don't even want to go out. They just want to pop a pizza in the microwave, fall asleep on the couch watching TV---and then go to bed at 11 pm, ready for that good night sleep that will make all the difference.
In the 19th century, people did not know that what they could not see, smell or taste could kill them. That's because they could only see it with a microscope. In the 21st century, people do not know what happens when they are unconscious can kill them. That's because it only happens when they are unconscious.
By now some of you know that I am talking about sleep disorders. More of you know that I am writing about sleep disorders than members of the average population would know if forced to read this. You are reading this because it has the words "public health" in it, and therefore you have an interest in health. Since those reading this have an interest in health, 100% of you should know all about sleep disorders, one of the most common chronic medical conditions in our society today. 100% of you should know how you sleep, whether you snore or stop breathing, whether you grind your teeth, whether you kick all night, because you will have made a point of asking friends and family---it is very important that we know how we sleep.
Sadly, more of you probably know your ldl cholesterol than know about your own sleep. More of you have probably asked your significant other "Are there any funny looking moles on my back that might be cancerous?" than have asked "Do I show signs of restless leg syndrome?"
Sleep disorders are one of those tricky medical conditions that do not announce themselves with a great big billboard, the way that--say--angina from coronary artery disease does. When you are carrying the groceries in the house and suddenly a bull elephant is sitting on your chest and you have been transported from sea level to the top of Mount Everest and your head is swimming and you feel like puking---when all that happens, you listen.
Sleep disorders are more like high blood pressure. Sometimes you get symptoms, more often you don't. Once upon a time, no one knew their blood pressure. Now, you can get it checked in the grocery store. Almost every adult knows that blood pressure is important. So is cholesterol. So is blood sugar. So is not smoking. If you want to avoid a heart attack, you pay attention to these things---and heart disease is the number one killer in this country right now.
Pop quiz. Name another independent risk factor for heart disease. You said obesity, didn't you? Close. Sleep apnea. Name a risk for car wreck--besides DUI. Blindness? I guess so. But most blind people know not to drive. People who are sleep deprived do not know that they are sleep deprived, because they were unconscious when their body was failing to get restful, restorative sleep.
Our current insurance system, which offers many of us essentially no insurance between the ages of 40 and 65---too many pre-existing conditions to get individual policies and not yet old enough for Medicare---has contributed to the sleep apnea crisis. When folks reach 40 and the sleep disorder they inherited from Mom kicks in, they do not know that they have a sleep disorder. They know that they have high blood pressure, depression, fibromyalgia, erectile dysfunction, low back pain, migraine headaches---and they can no longer perform the necessary functions of their jobs so they make mistakes and get fired.
Once they start working as a cashier at Quickee Mart, they no longer have health insurance, so even if they begin to suspect that there is something wrong with their sleep, they can not see a doctor and get tested. But most of them do not suspect. They know that they can not work and so they file for Social Security Disability. They are turned down because high blood pressure, depression, fibromyalgia, erectile dysfunction, low back pain, migraine headaches can not keep a person from working--the judge knows this. If the people appealing their disability denial could bring in the results of a pulse oximetry test done overnight or a sleep study showing that they stop breathing 60 times an hour, the judge would exclaim "You have sleep apnea! No wonder you can't work! Here's your Medicare. Get that treated!"
No, this is not a fairy tale. I have lost track of the number of patients whom I treat at a public health clinic for the uninsured who lost their jobs and insurance due to a sleep disorder that their old doctors never suspected and who are able to successfully appeal their disability denial and get Medicare---insurance!---once they prove to the judge that there really is something wrong with them. I have lost count of the number of people who think that I am psychic, because I look over their medical record and ask "Do you snore or stop breathing at night?" No, I am not psychic. I just have first hand experience with what it is like to have an unrecognized sleep disorder that costs you your career in the prime of your life.
Now, on to the revolution. This is not how it should be. People who develop sleep disorders in middle age should not lose their memory, their energy, their concentration and finally their jobs because doctors are so bad at diagnosing sleep disorders. This should be one the first things that their doctor screens them for when they first go in saying "I can't remember things. My driving sucks. I can't get an erection. I hurt all over." They should not go into their doctor's office unaware of their own snoring, apnea, restless leg jerks and bruxism, since---being educated professionals---they keep track of their own health. They should not be forced out of the professional job market and into the hourly minimum wage job market just when their professional skills are at their best. They should not have to leave the job market altogether---in effect, retire---in order to get their sleep disorder treated. If they and their doctors recognized the first clues about a sleep disorder and started treatment while the patient was still employed with insurance and did not carry the stigma of long term unemployment, a big chunk of the American workforce would continue to be productive beyond Medicare retirement age---and we would never have to worry about Medicare and Social Security going bankrupt.
Ten percent of Americans over 40 have a sleep disorder. 80% of them do not know it. Among them are professionals like me, a family physician. Society lost ten years of my medical skills, because neither I nor my doctors knew what was wrong with me for years after I retired. And then, after I figured it out and got treatment, I had to scramble to find a way to get back into a workforce that does not trust those who have been out of it, it would rather see you stay on disability and Medicare, just to be safe.
As we move closer to the goal of Cradle to Grave Insurance for all of us, those who pay the bills will have an incentive to keep us healthy. As it stands, Blue Cross would just as soon see your sleep apnea go untreated--if it means you lose your job and your insurance. If Blue Cross is going to pay your medical bills whether you can work or not, Blue Cross wants you as healthy as possible---because people with undiagnosed sleep disorders accumulate thousands of dollars a year in unnecessary medical tests and treatments, and if you have Cradle to Grave insurance, Blue Cross will have to pick up that bill. Blue Cross (and United and Aetna and Medicaid and Medicare) will realize that increasing physician and public awareness of sleep disorders will keep you healthier and save them money.
Eventually, you will see pamphlets like the ones that the American Cancer Society used to hand out with the 10 warning signs of cancer. Yes, once upon a time, people did not know that rectal bleeding could be a sign of cancer that could be treated and cured if found early. One day, they will know that snoring can be a sign of a serious medical condition that is treatable--if found before you die in a car wreck or of a stroke. Eventually, High School Health classes will teach sleep hygiene. Eventually, no one would dream of NOT telling you "You snored and stopped breathing last night" anymore than they would dream of NOT telling you "Don't eat that potato salad. It was left out all night. There is no telling what kind of bacteria are growing on it."
Raise sleep medicine awareness. Keep our roads safer. Keep middle aged workers at their jobs longer. Reduce the strain on Social Security and Medicare. It's gonna happen. The only variable to the equation is when.
And, as before, if you want a free Word document copy of "Life After CPAP" send me an email at McCamyTaylor@earthlink.net
Posted by McCamy Taylor | Wed Feb 12, 2014, 04:38 PM (10 replies)
In 1999, under my maiden name I published a short book about so called managed care---"Damaged Care" as it was sometimes called at the time. HMOs or Managed Care failed due to physician and patient concern that they were damaging the doctor-patient relationship and leading to poor quality care. In particular the idea of paying doctors NOT to provide care or to turn away SICK people did not set well with many people---including doctors. Laws were passed to prevent HMO abuses. Most people dumped their HMO for a PPO--a plan that provided better payment for in network providers but had an out of network option as well.
Well, don't look now, but the economic forces that lead to the creation of HMOs are in play again. Insurers now must take all comers, regardless of pre-existing conditions. They can no longer "cherry pick" healthy people in the individual markets. If your aunt on dialysis wants to sign up for United Health, she can. If your brother who is on a liver transplant list decides to pick Blue Cross, Blue Cross is stuck with him.
Since insurers make money in only one way---by collecting more in premiums than they pay out in benefits--the ACA puts them at tremendous risk. And risk is something that the health insurance industry does not want. In order to cut its losses, the industry will try to do what it did in the 1990s---limit care, drive away the sick, make it difficult for doctors to care for those who need care the most. Their goal is to make all the sick people abandon ship while keeping the healthy members happy. Their ultimate goal is to force all the "sick" people on government funded Medicare and Medicaid while collecting federal payments for healthy people. How do they hope to accomplish this? The same way they did it back in the 1990s.
Some things have changed from the 1990s, but some are all too familiar. People who are trying to use their shiny, new silver plated insurance for the first time are discovering that their specialists are NOT on their plan (they were promised that they would be). If they belonged to an HMO in the 1990s and if they had read my book back then, they would not be surprised, because they would know that "Member Services Always Lies." They are beginning to realize that finding doctors and providers on their new insurance can be difficult if not impossible. There are new rules and regulations that make so sense. Barriers to care are thrown up that seem to serve no purpose except to frustrate and frighten patients--and that is exactly what they are trying to do. Scare away "sick" people while keeping the "healthy" folks happy. Insurers have found new ways to reward doctors for treating only the healthiest patients--they call it "Pay for performance". And since "poor" often equals "sick" in this country, one way they can limit their liability is by having only a limited number of doctors and providers that serve in poor or minority areas.
After reading about some early bad experiences that people are having in California, I decided to revise and update "Damaged Care" for the 21st century. Some parts are left out. Some are modified. New sections have been added to address issues that are unique to the ACA. The book, "Damaged Care Redux" is now available in electronic form now for FREE at Amazon at http://www.amazon.com/...
If you do not have a Kindle and can not download Kindle books on your computer, send me an email at McCamyTaylor@earthlink.net and I will send you a Word manuscript at no charge. If you want a copy of "Life After CPAP" I can send that, too.
I am a family physician with a Master's Public Health. I work in a public clinic for the uninsured but I see a lot of so called Medicare Advantage Plan patients too, because their insurance does not have enough doctors to meet their needs. Pretty sad when someone with insurance has to rely on a clinic for the uninsured to get care.
Remember, an informed consumer is a healthier consumer.
Posted by McCamy Taylor | Tue Feb 11, 2014, 07:33 PM (0 replies)
Hi, longtime, no see, DU. I am not writing political journals very much, now that we no longer have our Selected President Bush. I spend my days practicing medicine and writing an occasional piece about health disparities along with a lot of fiction, which is what I prefer to write (when we do not have a Supreme Court coup).
Below is a link to the e-book I Just wrote, "Life After CPAP: A physician's experience with Obstructive Sleep Apnea, the Most Commonly Missed Common Diagnosis in the U.S." I am a family physician working at a large urban public clinic. I also have a Master's Public Health in the area of health education. I wrote this book as first person narrative, because I think that many readers will recognize themselves, and health ed messages are more effective if the target/reader thinks "This applies to me!"
I was disabled for ten years, unable to work as a physician, because it took three years for my doctors to figure out that I had sleep apnea. And they only solved the mystery after my husband (not a doctor) made the diagnosis. It took me several more years to get my OSA under control.
The e-book is free for Kindle for five days, then I will have to start charging for it as per Amazon policy. If you don't have a Kindle and are broke because you can't work because you don't know that you have OSA or can't get it treated without insurance but you do have a computer---which probably applies to everyone here---I can also send a free word document to anyone who e-mails me at McCamyTaylor@earthlink. net. This is intended to be a health resource, not a money making venture. This is NOT a screed against CPAP. CPAP works great in about a quarter to a half of the people with OSA. It didn't work for me---and in the book I spell out exactly why it did not work for me and I go over a lot of other treatment options that work. I have done research (physician surveys) about why primary care doctors are so bad at diagnosing sleep disorders. I have a few suggestions for how we can improve our doctors' diagnostic skills. Most of them involved increased public awareness--which is another reason I have written this. This book is also an attempt to make the initial diagnosis easier, because if you don't know you have sleep apnea, you will go around chasing your tail treating all the complications. Sleep apnea is now a particular area of interest of mine in practice, since so many of the disabled uninsured that we see got that way because when they had insurance, their doctors did not notice that they had a sleep disorder, and the complications of untreated sleep apnea got them fired. If they had only known about their health condition, they could have kept their jobs by getting treatment and taking advantage of special laws that protect the disabled until their OSA improved. I also see a lot of people who qualify for Social Security disability but who keep getting turned down, because they do not know that they have OSA--a condition which the government considers disabling if it is severe enough. If you get Social Security, you (eventually) get Medicare--and then you get treatment and get back to being your own self and maybe even back to work, the way that I did.
If you have fibromyalgia, migraine headaches, hard to control BP, ED, nocturnal angina and mini-strokes, depression that does not respond to medication, poor driving skills, memory loss, over 40 sudden onset "ADD" and doctors can not tell you what is wrong with you, there is a very high chance that you have an undiagnosed sleep disorder. OSA--obstructive sleep apnea--is the most common of these.
Posted by McCamy Taylor | Wed Jan 15, 2014, 02:25 PM (3 replies)