Wasting Taxpayers Money, Medicare Advantage and the RAC’s

My wife and I try to catch up on TV shows on Thursday evenings. We sit down with a cup of decaffeinated coffee on the couch together petting our dogs and watching mindless entertainment after a day at work. Now that the election is over, almost every commercial in my South Florida market is an advertisement for a Medicare Advantage Health Plan. We are nearing the completion of the “open enrollment” period between October 15 – December 7 when senior citizens can change their Medicare Part D Prescription Plan to one that covers their formulary of medicines and they can choose to leave the Medicare system and join a private health plan for a capitated Medicare Advantage Plan. These plans were initiated by the Center for Medicare Services (CMS) as a way to save money on the health care of seniors. The theory was that if they offered a product with a fixed monthly and yearly cost budgeting would be simpler and at least they would know what they are paying.

These programs are run by private insurance companies such as Humana, Blue Cross Blue Shield, and Aetna. Over the years, research has shown that they now cost the Medicare system more money per year, per patient, than the traditional Medicare system. The private insurers are probably making a great profit on this program because the money and energy spent on advertising to attract patients is relentless. I have been receiving multiple daily promotional letters in the mail for weeks now. Full page ads are run daily in major newspapers and magazines. Prime time television is filled with expensive ads with noteworthy spokespersons like basketball hall of famer Ervin “Magic” Johnson in addition to actors, actresses and former elected officials.

The insurers make their money by rationing and denying care provided by doctors and hospitals which agree to see patients in volume for a discounted fee. Patients have no deductibles; have no out-of-pocket expenses for physician care or generic pharmaceutical products if they stay in network. If they happen to get sick out of the service area, coverage is spotty and varies by program with the advice truly being “buyer beware.”

It seems to me that if these programs are actually more expensive per patient than traditional Medicare then why is CMS continuing them and allowing the millions of dollars spent on advertising to attract patients to continue? The information they need to choose a plan is available on the easy to use http://www.Medicare.gov website at no cost.

I open some non-critical advertisement mail as well. One letter from the Center for Medicare Services addressed to me personally as a patient, not as a physician, was extremely interesting. In December 2014 I was involved in a serious auto accident with my vehicle totally damaged due to the negligence of another driver. I was taken by ambulance to the local emergency room, examined, treated and released. At the time I was 64 years old and several months short of being eligible for Medicare. My auto insurance paid my medical bills. My private insurer Blue Cross Blue Shield was not billed.

The letter from CMS was a form letter saying that a claim from December 2014 had been investigated by them and although no payment was made on this claim, which was paid by Traveler’s Insurance (my auto insurer), they were now referring it to the Recovery and Audit Division for further investigation. The threatening nature of the letter suggested that if I was compensated by Medicare for this claim I would be required to pay back the money with interest and penalties. Considering I was not yet on Medicare, and considering the charges were billed by the local hospital health system, I am not quite sure why the letter was generated and forwarded to me?

Once again a government agency is spending taxpayer money on a frivolous item. How many more of these letters go out yearly at our expense?

The second letter I opened was from Social Security. It said that since I was still working and generating income, my wife and I would be required to each pay an additional fee per month for our Medicare health insurance and for our Medicare Part D prescription drug plan. This is in addition to the tax on my salary that goes directly to Medicare. I have been paying this tax on each paycheck since I started working at age 14 (I am now approaching 69). I read this letter just after hearing one of our elected officials to the Senate refer to Medicare as an “entitlement program.”

My Medicare bills now approach what private insurers charge patients for health insurance. I paid into this system for 51 years before I became eligible to use it. I hardly think the Medicare system is an entitlement.

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Medicare Payment Figures Released

Center for Medicare ServicesThe Center for Medicare Services (CMS) parent organization of the Medicare program, released detailed raw data showing how much providers of Medicare services are paid. For many years, hospitals and physician organizations have battled to keep this information private from the media, the public and private health insurance companies. As a citizen I have no problem with transparency, but if in fact we are asked to show our payments from Medicare then I believe every other individual and business
should be required to have their federal payments revealed to the public and media as well.

The data revealed that a physician in West Palm Beach, who treats diseases of the eyes in the elderly, received 21 million dollars from Medicare during the time period reviewed, leading the country in individual payments. That physician claims that most of the payment was for a drug called Lucentis injected into the eyes of seniors with macular degeneration a potentially sight ending disease. The problem is that other experts claim that a less expensive drug, injected into the eye produces equal or better results for far less cost. If the less expensive drug produces equal or better results then why is Medicare still paying for Lucentis, except in cases where the patient is allergic to the cheaper alternative or where it has not worked? CMS has the ability to control its payments for ineffective products. It just chooses not to do so. The NY Times made a big splash headline of the fact that this physician made a sizeable political contribution to a political party and then asked elected officials to look into why he was being singled out for repeated Medicare audits? Yes Medicare has the right to review each chart and determine if the treatment was indicated, if it was provided, if it was documented and then billed per their extensive rules and regulations. CMS makes the rules. If the physician follows those rules then it is inappropriate to slander him and accuse him and ask the tabloids to do what CMS could not do because the physician was in fact playing by their rules!

At the same time that CMS released this data, organized crime continues to profit from Medicare fraud in south Florida, particularly in Dade and Broward Counties because it is less risky to commit Medicare fraud than it is to run drugs, prostitution, human trafficking and loan sharking. Maybe CMS should be trying to stop the flow of low hanging criminal fraud rather than releasing data on provider payment. As the storm clouds gather over the use of this data, ObamaCare seems to have reached its enrollment goals despite major startup problems. Despite this, Kathleen Sebellius, the CMS director resigned. Do you think it had something to do with the inappropriateness of the payment data release and the ultimate consequences?

The Business of Medicine Should Not and Can Not Replace Care and Compassion

Compassionate CareWell over a year ago I advised my 80 something year old patient and her children that due to progression of her Parkinson’s disease, and her frail nature, she needed a higher level of assistance and care if she wished to remain in her home.  She was extremely unsteady walking and several courses of physical therapy had not improved the situation. The patient was feisty and would only allow help to come for 4 hours per day despite having a long term care policy that paid for significantly more.  She lost her balance recently, fell and landed on her back. She could not get up or get to a phone or her alert bracelet and was found seven hours later on the floor by her aide arriving for work.  In the Emergency Room x-rays revealed several acute fractures of her vertebrae that accounted for her severe pain with movement and inability to stand, bear weight or walk.

I hustled over to the ER and examined her and called the interventional radiologist to see if he could perform a procedure called a kyphoplasty that would cement the fractures and remove the pain. It was early Friday afternoon and the traditional back specialists were unavailable until the next day.  The radiologist came promptly, was professional and very pleasant explaining that he could do the procedure but because she took a baby aspirin for prevention of stroke, he would not perform it until the aspirin wore off in 5 – 7 days because of fear of excessive bleeding around the spinal cord.  He suggested we send her home with pain medications and round the clock assistance or keep her in the hospital until the aspirin wore off and he felt comfortable performing the procedure.  He was courteous and a credit to any profession. 

Since the patient was in great pain with any movement, I chose to admit her to the hospital while we sorted things out.  I admitted her as an inpatient because she is extremely elderly and frail with medical conditions that led to this injury which an expert had just told me required surgery to fix. She could not walk or transfer to a chair or wheelchair to get food, water or get to the bathroom. She had no arrangements for additional help at home to assist her. She could not, in my professional opinion, go home safely at this point.  

The next day I was making rounds late in the day for me at noon, reviewing the situation with the patient and her son when the physician’s assistant (PA) for the back surgeons, Andy, walked in and introduced himself. They had not seen her Friday evening or Saturday morning and this was their first contact with the patient.  My consult request and phone call had been quite clear. I wanted to know how they viewed the injury and what options did they feel were best to fix the problem. I additionally asked them how their approach would differ, if at all, from the approach of interventional radiology.  I had seen Andy around the facility and said “hello” but never formally met him so it was an introduction for me as well. 

“Hi, my name is Andy, and I work for Doctors Y and Z.  We have a little problem with your insurance.  You have a Medicare Advantage plan and we are not part of that plan. Most of the time, about 95% of the time, we eventually get paid for our services but we need to know how we will get paid for performing a procedure on you to fix your back before we proceed further. In these situations we usually ask the patient to pay the bill up front ($1000 – $1200) and then we submit the charges to your insurance company. If we get reimbursed from the insurance we return the money to you.”  

I took a deep breath and wondered if maybe I was overreacting to the brusque inappropriate presentation to a groggy senior who had been given a narcotic 30 minutes before for pain and was really in no condition to listen to any presentation or sign away informed consent.  I cut Andy off in the middle of a sentence and reminded him that I had requested an opinion. The son, an attorney by trade took up the fight and reminded the PA just how inappropriate his initial remarks were and that in this case money was not a problem but the manner of dealing with an elderly confused patient was.  I played mediator at this point and got the PA to explain that his employers had done several thousand of these procedures and handled many more complications than most interventional radiologists and that their success record spoke for itself.  He outlined a slightly different approach and once we got him talking about the reasons for his invitation onto the case, justified calling his group.

I am all in favor of physicians being paid for their professional services. This could have been handled differently by calling me first and informing me that they had concerns about payment and insurance and letting me address the issues. It could have been handled far gentler by answering the questions asked first and suggesting options and then reviewing the problems with the insurance. Had the gentleman performed a history and or exam rather than rely on the ER PA’s evaluation the day before, he would have seen that the patient was not in a position to comprehend what he was saying or sign for a procedure.  

This is not a criticism of PA’s or Nurse Practitioners. It is a criticism of any practitioner who does not answer the questions asked by the referring physician or question the referring physician about payment before arriving for the consult if they have questions about getting paid for their time and expertise.

The post script is that the son wisely chose to use this group based on their talents and experience and put aside the rude and insensitive communication by the PA. The surgery went well and the patient will go home after spending three nights in the hospital. 

There is still one obstacle to overcome. The hospital ignored my written order to make her status inpatient and made her status observation which will prevent her from receiving any post-surgery therapy or care which is paid for by her insurance. I will fix that. Keeping the phone number on my phone contact list of the Office of the Inspector General who investigates Medicare irregularities opens doors in situations like this. It does not change the fact however that as practitioners we need to be much more thoughtful when we discuss financial issues before medical issues if we wish to continue to be considered a profession rather than another business.

Medicare Part D – Who Is Watching the Henhouse?

Medicare MontageOctober through December 7th is the time of year when patients should be re-evaluating their Medicare Part D Drug Plan and their private insurance options.  Medicare patients are encouraged to log on to www.medicare.gov and access prescription drug plans. They are asked to enter their Medicare identification number, zip code, name and then their prescription medications. The computer will then find them the most cost effective drug plan in their area for their medication needs. 

This process is so important that I always remind my patients about it in our practice quarterly newsletter and offer to perform the service for those patients who are not computer literate or who just do not get it. It is additionally the time of year when patients begin to receive notification that some of the medications covered on their Medicare Part D Prescription Plan formulary, or on their private plans, will not be covered the next year and they will need to change. 

This is not a particularly difficult action for younger healthier patients taking few prescription drugs but it does become challenging for the elderly on multiple medications for many chronic diseases and problems. There is no organization or government office supervising or monitoring this process and it can lead to problems. Take the example of TJ, an 84 year old woman with long term sleep problems, coronary artery disease, intermittent congestive heart failure, chronic kidney disease, high blood pressure , elevated cholesterol, spinal stenosis, diffuse osteoarthritis and age appropriate short term memory loss. After seeing a neurologist she has been placed on temazepam 15 mg one half tablet at bedtime as needed for sleep. She purchased a Medicare Part D Prescription Drug Plan through AARP because of her trust in that organization.  They contract with United Healthcare to provide the Medicare Part D Drug Insurance Plan. 

In 2013 a 30 day supply of temazepam cost the patient $10 per month. The notice says that in 2014 that same medication will cost the patient $85/month if she buys the generic version or $95 per month if she wishes to purchase the brand name version. Her AARP United Healthcare is suggesting that in 2014 she switch from temazepam to trazodone.  Trazodone will only cost her $7 per month for the generic version. Trazodone is an antidepressant drug which was found to be sedating and has now obtained permission to be used for insomnia.  In my humble opinion comparing one half of a 15 mg temazepam to 50 mg of trazodone for sleep is like comparing a small ceremonial glass of wine consumed at a religious service to snorting a few lines of cocaine (a stimulant), and then taking a few shots of vodka to slow the shakes of your hands before you go out and drive carpool.

Our small office caught this error in judgment and prevented the change. We wonder who exactly at the drug plan considered the difference in medications in this senior citizen and approved this?  How much money, favors or gifts exchanged hands at the purchasing and corporate level to negotiate this change in formulary.  If this patient was in a larger practice with little oversight would this change in medications been handled and approved by non-medical staff with no questions asked? 

Patients who put their trust and faith in AARP deserve better oversight and regulation.  This is one case but how many thousands more are slipping through in the name of greed and corporate profits?

Medicare Advantage is not Medicare!

MedicareCMS the parent organization of Medicare has gone to the private sector and contracted with private health insurance companies including United Healthcare, Blue Cross Blue Shield, Aetna, Cigna and others to offer a private managed care insurance product to Medicare age recipients.  CMS or “Uncle Sam” is supposed to pay a flat fee for all the services rendered to a Medicare recipient to the private insurer to cover their enrollees’ medical needs. The fee was originally 95% of what Medicare paid on the average for a Medicare patient annually. This was supposed to save the government money.  In exchange for that annual fee the insurer or Medicare Advantage plan is supposed to cover your health care, provide pharmaceutical coverage and products and provide a set of extras or enhancements such as eye glasses, sneakers, gym memberships for wellness programs. It is managed care. There are strict rules and regulations about who you can and cannot see as a physician. There is a strict formulary of medications and there are contracted institutions you must go to such as hospitals, labs and imaging centers to receive appropriate tests. For the coverage to apply you must see a physician contracted to that insurance company’s panel. Non-emergency hospital admissions, trips to the emergency room and post illness care are all subject to the approval and review of non-physician personnel before the insurance company will pay for it. You lose your choice of going to the best institution or practitioner in exchange for lower up front monthly costs, minimal or no co-pays, no out of pocket pharmaceutical donut hole costs and the extras, glasses, sneakers, gym memberships.  You are issued a Medicare identification card that is virtually indistinguishable from the card a traditional Medicare patient uses. It is less expensive to the patient and works wonderfully if you are healthy and do not need health care.  Unfortunately individuals over 65 years old usually have or develop medical issues frequently.

B.J. is an 89 year old retired physician who got his Medicare Advantage plan through his medical society in the NY metropolitan area. He suffered a series of small strokes and was hospitalized for four days after being brought to the hospital by the paramedics on an urgent basis. His speech was impaired, his strength and balance did not allow him to walk without assistance. He was swallowing poorly with food as likely to end up going down the wrong pipe and choking him as it was to get into his stomach, so nutrition was an issue.  His wife and daughter did not feel he could go from the hospital directly home because he was too weak to walk.  His elderly wife could not handle him in this weakened state.  I suggested a short stay in a skilled nursing facility for strengthening, gait and balance training and speech therapy to rejuvenate his swallowing process safely.  We checked on the bed availability at three of the facilities in our area that did a nice job with this type of problem and there was bed availability. His health insurance was a Medicare Advantage plan, the Empire plan. They wanted him to be placed in a facility that I would not send my worst enemy to. They wanted him to go home from the hospital. The hospital case manager and I spent two days arguing with them about the need for placement, extending the patient’s hospital stay by two days and then they only approved a two day stay with a reassessment to be done on the third day which was a Saturday.   Had he been a traditional Medicare patient we would have sent him to the best place for his problem and he would have been eligible to stay for 21-30 days with full coverage. Post illness care can be a problem with Medicare Advantage plans.

Then there was H.B. a 69 year old overweight hypertensive man, still running his business, with new onset of significant shortness of breath and chest heaviness when walking a short distance.  We called the cardiologist “on the plan” who set up an appointment two weeks later. I called him to discuss the need for a timelier visit but it is managed care and that is the best he could do. . The cardiologist ordered a nuclear stress test after seeing him. This required approval again and this took his staff three more days. The test was scheduled for a week after that.  He flunked that test. The cardiologist wished to perform an angiogram to look for blockages. He referred the patient to an interventional cardiologist on the plan who could not see the patient for three weeks.  He saw the patient three weeks later and recommended doing a cardiac catheterization or angiogram.  It was scheduled for the next week instead of the next day as it should have been. When the patient arrived early in the morning for his catheterization as an outpatient he was told that the insurance company had not yet approved the procedure. He lay on a gurney from 7am until 2:35 PM without getting approval, or fluids, or a meal.  At 2:40 PM they sent him home. This occurred two more times on two separate days before the approval was obtained. The angiogram showed a 97% blockage of a left main coronary artery which they could not pass a stent through.  Try as they might they could not get it through. The interventional cardiologist was the practitioner under contract to the plan not necessarily one of my top choices or the most skilled in our area for that problem. He called in a cardiovascular surgeon to bypass the lesion surgically.  He took him to the ER later that day and successfully bypassed the blockage.  He approached me after the procedure and asked me, “Why did you guys wait so long to get him tested and some treatment. He was lucky with that “widow maker lesion that he didn’t drop dead. Why did it take eight weeks to get him fixed? ”

The next few months are the open enrollment period for individuals who qualify for Medicare to either stay in the traditional program or switch to a Medicare Advantage plan.  Managed care Medicare Advantage plans work well if you are healthy and if your budget does not allow you to buy a co- insurance policy and pay any portion of your prescription medication costs. If you sign up for the Medicare Advantage plan you to relinquish your choices. Think twice before you give up your freedom and choice to save a few dollars per month.