financially-driven medical decision-making

One of my assumptions about medicine is that continuity of care--that is, working with the same set of providers for a long time--has benefits. They flow mostly from the trust that is established with a primary provider, but can also come from information-sharing. This is something I really work at: I took my kids to the same pediatrician and followed him from a convenient office near our house, to a less convenient office in another suburb, to a really inconvenient one in yet a third for twenty years. I also make sure records get sent between specialists, etc., etc. IOW, I'm kind of a pain in the ass in the interests of making sure me and mine are well-cared-for.

I need to have a dilated eye exam every year because of one of my chronic conditions, and I'm due for that exam now.

I went to the same ophthalmologist for many years (as have my other family members who need eye doctorin'). He dropped out of our network last year, for which I do not blame him one bit.

Because I don't need my current doc's artistry with vision correction any more, having two bionic eyes, I found a new guy in the state to which I am moving by referral from my main provider in the new state a few weeks ago. I made an appointment for September (the earliest available) to establish that new, coordinated relationship.This was a little later than ideal, but I can live with it.

Found out yesterday, however, that our high deductible, which we have already satisfied for 2017, *resets* at the end of July. So my options are: (1) go back one last time to my long time guy, and pay the high out-of-network rate; (2) keep my September appointment with the new guy and pay his in-network rate, but applied towards our reset deductible; or (3) find a rando in-network before I move, and have a single eye exam at the cost of our modest co-insurance. It's a several-hundred dollar decision.

After due consideration, I conclude that establishing a relationship with my new eye guy next year rather than this year, since I'm not having eye problems right now, is probably not worth paying that much. Sigh.

The layer of complexity that financial considerations add to what should be a simple scheduling decision is exhausting at times.

more fun with PBM appeals

The PBM denied the first appeal (more on that later).

The form called "Important Information about Your Appeal Rights" provides a number to call "for information on how to designate an authorized representative."

I try looking on the PBM website first and cannot find an authorized representative form.

I call that number to get the form. Person #1 gives me a URL that leads to a 404 notice (big surprise).
She transfers me to Person #2 at a new phone number.

I ask person #2 for the information on how to designate an authorized representative to file an appeal.
She has no idea talks to her supervisor.

She comes back and tells me that her supervisor says I have to fill out the form and send it in.
I explain that I am calling because I need the form.

"Oh," she says, "my supervisor says you have to get it from the website."

I explain that neither person #1 nor I could find it on the website.

"Oh," she says, "I have to transfer you to person #3 at yet another phone number!"

At which point I am disconnected.

I am in Hell.

i don't know how other people do this

I submitted a claim last month on behalf of a family member for a compound prescription medication (eye drops with a higher percentage of active ingredient than readily available).

The claim was denied by our PBM because, according to them, it "contains non-covered ingredient(s). Your prescription drug plan does not cover this medication."

The denial did not identify which of the "ingredient(s)" were allegedly not covered.

The compound prescription had four (4) listed ingredients, including sodium chloride (at a cost of seven cents).

Here is what I had to do in order to appeal the claim.

(1) I looked at the original form from the compounding pharmacist and developed a hypothesis that there was only one active ingredient.
(2) I went to the website of our PBM and searched their current formulary. I found the same delivery system of the same active ingredient (at a different concentration) listed, and printed out the page proving that the active ingredient was covered.
(3) I went to DailyMeds and printed out the drug information, including the ingredients list, confirming my hypothesis about which of the four ingredients was the active one and also proving that the three inactive ingredients in the compounded prescription were also used as a buffer in the formulary drug.
(4) I filled out the appeal packet, explaining all this and attaching the denial letter, the claim showing the list of ingredients, the page from the formulary showing that the medication was generally covered and the drug information showing that the inactive ingredients were the same.
(5) I mailed the appeal certified mail, return receipt requested, because I don't trust these people to keep track of anything anymore.

The worst part of all this is that the compounding pharmacy charged us less than the listed price of the formulary drug. So going this route should save the PBM money.

Of course, just denying the claim outright was even cheaper.

At first.

But I have to wonder. What do people do without good research and verbal skills and some knowledge of chemistry?

possibly the most boring post i will ever write

Apparently, my health insurer Aetna, which is actually not an "insurer" at all but a TPA, is changing PBMs from Express Scripts to CVS Caremark.

To decode that last sentence and its significance:

A "TPA" is a third-party administrator of the health benefits that are being provided by a large company which is actually "self-insured."  When you are dealing with health benefits you need to understand who is actually providing them because you need to understand the rules that govern them and the pressure points if you need to complain when things go awry. For example, generally speaking, a self-insured plan isn't going to fall under the jurisdiction of the Commissioner of Insurance for your state, so cc'ing them on a Stiff Note is really not much of an implied threat. Self-insured plans fall under the loving care of the feds, in particular the Department of Labor and the Internal Revenue Service, but they tend not to be that consumer-oriented. Also, they're really busy.

A PBM is a "pharmacy benefits manager." This is a subset of TPAs in charge of arranging for payment (or not) of medications and (some types of sort-of DME, see digression below) prescribed by the clinicians who are paid for by the benefits administered by another TPA. Because that is more efficient (it actually may be, for all I know. Pardon my momentary cynicism).

The PBM switch has apparently been in the works for a while, and I am pretty sure that the transition was contemplated to occur in 2017 (like, January 2017).

The hotlink on Aetna's website to the press release announcing its "strategic alliance" is, of course, broken (when I pointed this out to the Health Advocate she actually snorted).

The "Q and A for Aetna Members" says "we will keep your employer informed."

The employer (of the consort of the Dark Goddess) knows nothing of when or how the PBM transition will be implemented. For all I know the deal fell through or was blocked by the Justice Department on antitrust grounds.

Our family is strong-armed into ordering a great deal of our medication (and certain types of sort-of DME, see digression below) through a PBM or face stiff financial penalties for the "luxury" of using a retail pharmacy. I have no information about how our scripts currently residing at Express Scripts currently eligible for refill will or will not be transferred to CVS Caremark, and when. Maybe it will be seamless. I should note that historically there has been considerable lag time between the time when we mail our prescriptions from Washington state to the processing center, which always seems to be in Florida, and the time the prescriptions are shipped from some other far-flung part of the country. When I can coax a clinician into e-prescribing, that reduces the transit time of one leg, but only one leg, of the journey.

My promised digression: one of the great oddities of my current PBM is that, if you get a "prescription" for medication that is available over-the-counter (for example, low-dose aspirin), the PBM will provide it essentially free (because this sort of preventive medication is regarded as a good investment in your health). Also, there are certain types of "durable medical equipment," or DME, also available over-the-counter, but that if "prescribed" are also provided more cheaply than if just purchased at the store. The oddity goes up to eleven when you realize that DME includes items that are not durable at all because they get used up, for example, lancets and glucose monitor test strips. And the rules on what DME you are "allowed" to buy from a pharmacy in order to have coverage are Byzantine. This summer I found out that my pharmacy was not a DME provider for crutches, but it was a DME provider for lancets and test strips, which was a distinction that was never satisfactorily explained to me.

Aside from the possible gap in fills, here are significant differences between the 2017 formularies of the two PBMs (the new one, of course, seems more restrictive than the old), so which PBM will be in place for the future is actually important for me to track down.

I have asked both Aetna and Health Advocates for information and we'll see who can clarify it first.

dear director of patient relations

I am new to your organization, so I have been reviewing carefully all the forms that were mailed to me in advance of my first appointment.

[Of course, this isn't because I'm new. I will review carefully every form you ever hand me. Fair warning.]

I noted with interest the following language:

[This me trying to be tactful.]

"We allow 30 days from billing for your insurance company to make payment. If your account is not paid in that time, we will ask you for assistance to obtain payment from your insurance company."

You may only want to allow my insurance company 30 days to pay up, but as a matter of federal law, ERISA gives my insurance company 30 days to make a decision on a "post service" claim, which, if you are submitting billing to them, is what we are talking about here. They also might be able to ask for a 15-day extension in some circumstances.

What you seem to be saying to me is that unless my insurance company not only makes its decision on a shorter timeline than federal law gives them, but also gets a payment to you, you are going to start hounding me.

I assume that you are relying on the "prompt pay" statute in effect in your state in setting forth this policy. Prompt pay statutes haven't been faring well in federal courts lately, so there's a good chance that the whole thing is preempted by ERISA. Even if upheld, your statute doesn't give me a private right of action, and only requires my insurer to hit the target on 95% of "clean" claims. I could be in the five percent, and I have no control over whether the claim as submitted will be a "clean" claim as your state statute would require.

What I really want to know, as your new patient, is simply this:

How aggressive are you going to be about this language, given that you're a big institution, and my insurer is a big institution, and the dollars involved are more significant to me than to either of you?

don't judge a post by its title

So the article was called "Rethinking Automatic Insurance Coverage For Preventive Health Care" on the NPR website. Which sounds like a bad thing, right? Because of course it is good public policy (as opposed to a prudent business practice) to make preventive care "free" (that is, prepaid as part of health insurance premium) because it encourages more people to obtain the care. And so of course changing this policy sounds like some sort of skullduggery.

Well, there is skullduggery afoot, but it does not come from the U.S. Preventive Services Task Force (hereafter "USPSTF," which is a horrible acronym), the entity recommending the uncoupling.

Why are they making the recommendation? Mylan N.V., the company which has been jacking up the price of the EpiPen to the skies over the last few years, has been lobbying the USPSTF to list said EpiPen as a "preventive device," even though it is used to stop an allergic reaction, not prevent the reaction in the first place. I suppose you could say it prevents death, but by that logic all medicine is preventive.

If EpiPens were covered as preventive medication, patients with health insurance could get them at no cost. The price increases Mylan put in place would be invisible to consumers and would be borne by the insurers.

The USPSTF, not happy about being inserted into a dogfight between drug companies and insurance companies, is trying to depoliticize the recommendations.

So were I the Queen of NPR, which is not likely to happen in this lifetime, I would call the article: "When Defining 'Preventive' Health Care Becomes Politicized."

You're welcome, NPR.