Americans Struggle to Pay for Healthcare – 40% Delaying Treatments or Services

06/22/2009 — Nancy Sajben MD

A survey on health behavior from 100,000 households

*25 percent of households have trouble paying

*40 percent expect to delay care this summer

*Baby boomers hardest hit

“The percentage of households that had difficulty in paying for care in the last year was statistically unchanged between March and April (about 25 percent).”

They found 40 percent of all households planned to postpone care in the coming three months, with about 15 percent planning to put off routine doctor visits.

Baby Boomers were four times more likely than seniors to have trouble paying for healthcare, according to the report.

Not surprisingly, those on Medicare “were the least likely to delay care.” Youth were also less likely, probably because they have fewer health problems.

Posted in Controversy, Insurance, Politics of Pain. Tags: . Leave a Comment »

Poll: 76% Support For Choice Of Public Plan

06/18/2009 — Nancy Sajben MD

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New Poll Shows 76% Support For Choice Of Public Plan

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Excerpts from the Huffington Post summary:

New poll numbers from NBC/Wall Street Journal produce two major and potentially conflicting story lines when it comes to the Obama administration’s efforts for a health care overhaul.

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  • 76 percent of respondents said it was either “extremely” or “quite” important to “give people a choice of both a public plan administered by the federal government and a private plan for their health insurance.”

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  • [O]nly 33 percent of respondents said they thought the president’s health care plan, to the extent they knew of it, was a “good idea”

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  • But when read a description of the general outline — requiring insurance companies to cover pre-existing conditions, an employer mandate, tax credits for lower income families to buy coverage, and tax increases on wealthier Americans to pay for it – the number of respondents in support rose to 55 percent.

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Public option is not Single Payer. People know that “For profit” is not “For them.” Only a single payer plan such as Medicare lifts the burden from small and large business, puts people first over profit, and cuts out the middle men that crush the country’s financial future. It’s not perfect, but there is no rescission of coverage, no denial for pre-existing conditions, no inequality.

For all the denials from your PPO and the unaffordable medications you cannot receive, how many billions do insurance companies and pharmaceutical firms pay for advertising? Do you think your rates will stay the same if you had cancer or some critical illness that cost hundreds of thousands of dollars? How many months would you have to wait to get disability coverage? How much competition would there be for the shrinking public dollar then as the population expands and more need the same helping hand? Healthcare identity theft is increasing at a startling rate. If someone stole and used your insurance, as it now stands, your insurance company would hold you responsible for the hundreds of thousands of dollars of care they received. This black market would not exist if we had Single Payer insurance.

A fellow I know from England says that whenever anyone had a complex problem, they knew they’d get better care at the National Health Service Hospital, even though they could easily afford private care. Doctors there could participate in both plans. Private patients who paid more would be seen first, and others would wait to be seen as time permitted.cement truck

Before this all hardens into cement and we are stuck with business as usual and uncompromising profiteering, Robert Reich explains: How Pharma and Insurance Intend to Kill the Public Option, And What Obama and the Rest of Us Must Do.

Test yourself to see how difficult the decision is.  The Price of Life: When Healthcare Meets Money. Ask who would you want making these difficult decisions? A a select panel of expert physicians or Big Insurance? From COMMENTS on the article:

I don’t mind commenting on this subject.

The ‘Price of Life’ from a scientific or Human perspective:

If viewed from the drug manufacturer’s perspective, then it would be economic; return on investment.

But they have no power as to the availabililty of the product, except to the minority of patients who can pay. Not economically viable.

The target therefore, is private health organisations or health trusts

Whilst the former surely has the ability to pay, directly or from health insurance, they will still make up only a minority of the target population this drug was intended for.

The economics of research, development, manufacture and distribution must reflect the true target: Government funded health-care.

This was the intended target from the beginning. And it is based on guilt, an emotion large Corporations generally don’t feel.

The marketing fact is, ” We have invested an enormous amount of capital in a drug that never before existed, and if you can’t or refuse to provide this new medication, then it is you who must bear the consequences.”

Meaning criticism and real life consequences.

So, the guilt remains with the provider, and the carer. NOT the developer.

Limited resources, and TRIAGE.

The big Pharmaceutical Companies have access to the enormous funds required to develop new drugs.

But the balance between who pays and who benefits will be a major obstacle, until a public funded organisation can provide a similar service for free.

ISN’T THAT WHY WE ARE SCIENTISTS?Are we doing it for the money, or from intellectual morality?

You know that without Single Payer, Big Insurance will be making the decisions and you may lose your life, only their decision will be weighed against their profits.

Either way, unless you are independently wealthy, someone must make the hard choices. Unlimited cost is not a choice that can go on indefinitely. We’ve come to the end of the money line. We are paying top dollar for two wars, for worldwide economic crises brought on by mass greed and theft, and Big Insurance and Big Pharma want things to benefit them, not you, just like it always has. The public does not have a chance against their wealth and influence over Congress.

Game over before it begins. I can’t wait to hear laughter on the end of the line next time my patient’s medication is denied.

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believerjerk

Posted in Controversy, Insurance, Politics of Pain. Tags: . 1 Comment »

Haunted by the dirty work of managed care & that deadly piece of paper: “Denied”

06/17/2009 — Nancy Sajben MD

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“I know how managed care maims and kills patients”

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I will never forget the snarly laughter of a “medical” reviewer two weeks ago as he denied medication to my patient that the same PPO had been authorizing for years. My patient has been haunted by the man’s laughter since then. Denial of continuing medication is happening more and more despite California law that “grandfathers” in ongoing care for previously covered medication. See my post here.

It is “DESUETUDE.” It refers to the condition where a law has gone unenforced for so long that it is considered ‘obsolete.’ The law has not been repealed, but — here’s the clincher — the law has “collapsed into unenforcibility.” (quote from William M. Lamers, Jr, MD)

For years we have had spreadsheet medicine: Denial only for medication that is costly. It’s getting worse, more brazen.

Now that much new medication is unaffordable, priced far beyond the rate of a decade of inflation, what do we do with lawmakers that will not negotiate volume discount prices with pharmaceutical companies? How long will the middle class be able to afford common medication?  There isn’t another first world country on the planet that does not negotiate volume pricing.

Why are safe older pain medications being taken off the formulary?

Did you know that prices on best selling medicines may go up as much as 20 to 30% each year, though they’ve been on the market for years?

What is worse, managed care bloodlessly denies life saving procedures. A bloodless coup that rarely makes the news.

Physician Confesses to Congress, Choking Back Tears

Dr. Lynn DiPino [spelling?], former medical reviewer for Humana went before Congress to make “a public confession.”

This doctor, who acted as a reviewer for an insurance company, denied life saving surgery for a man and thus caused his death, saving “the company half a million dollars.”

Her decision to deny surgery insured her continued advancement in healthcare. “I went from making a few hundred dollars a week as a medical reviewer to an escalating six figure income as a physician executive.” “I was told repeatedly I was not denying care, I was simply denying payment. I know how managed care maims and kills patients. So I am here to tell you about the dirty work of managed care.”

As the video continues on the origins of managed care, it goes back to February 17, 1971, when Ehrlichman discusses Kaiser HMO with President Richard Nixon : “All the incentives are for less medical care because the less care they give, the more profit they make.”

Nixon smiles, his eyes narrow as if he is savoring fine wine, and says, “Not bad.”

Health Insurers Refuse to Limit Rescission of Coverage

withering criticism from Republican and Democratic Congress members

Today in Los Angeles Times

Even Republicans were appalled when “[e]xecutives of three of the nation’s largest health insurers told federal lawmakers in Washington on Tuesday that they would continue canceling medical coverage for some sick policyholders, despite withering criticism from Republican and Democratic members of Congress who decried the practice as unfair and abusive….

An investigation by the House Subcommittee on Oversight and Investigations showed that health insurers WellPoint Inc.[parent of Blue Cross of California], UnitedHealth Group and Assurant Inc. canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period.

It also found that policyholders with breast cancer, lymphoma and more than 1,000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses.

("Um . . I know this is a bad time but . . . .you're not covered.") shamelessly stolen from crooksandliars.com

("Um . . I know this is a bad time but . . . .you're not covered.") shamelessly stolen from crooksandliars.com

…Rescission was largely hidden until three years ago, when The Times launched a series of stories disclosing that insurers routinely canceled the medical coverage of individual policyholders who required expensive medical care.

…A Texas nurse said she lost her coverage, after she was diagnosed with aggressive breast cancer, for failing to disclose a visit to a dermatologist for acne.

The sister of an Illinois man who died of lymphoma said his policy was rescinded for the failure to report a possible aneurysm and gallstones that his physician noted in his chart but did not discuss with him.

The committee’s investigation found that WellPoint’s Blue Cross targeted individuals with more than 1,400 conditions, including breast cancer, lymphoma, pregnancy and high blood pressure. And the committee obtained documents that showed Blue Cross supervisors praised employees in performance reviews for rescinding policies.

One employee, for instance, received a perfect 5 for “exceptional performance” on an evaluation that noted the employee’s role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care.

…Late in the hearing, Stupak, the committee chairman, put the executives on the spot. Stupak asked each of them whether he would at least commit his company to immediately stop rescissions except where they could show “intentional fraud.”

The answer from all three executives:

“No.”

Rep. John Dingell (D-Mich.) said that a public insurance plan should be a part of any overhaul because it would force private companies to treat consumers fairly or risk losing them.

“This is precisely why we need a public option,” Dingell said.

…In November 2007, The Times reported that insurer Health Net Inc. paid bonuses to employees based in part on their involvement in rescinding policies. According to internal corporate documents disclosed through litigation, Health Net saved $35 million over six years by rescinding policies.

The disclosures in part led an arbitration judge to levy $9 million in damages against Health Net in a case involving the company’s rescission of the policy of a woman diagnosed with breast cancer.

At the time, Blue Cross told The Times that it did not link employee performance reviews to rescission. Blue Cross also said at the time that it had conducted audits to ensure that claims reviewers were not given any “carrots” for canceling coverage.

The company reiterated that position Tuesday in spite of the committee’s disclosure of two employee performance evaluations from 2003 discussing rescission levels and savings.

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Gene Wilder

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Gimme Some Money

by Spinal Tap

Condor

Posted in Controversy, Insurance, Liability, Medications, Politics of Pain. Tags: , . 1 Comment »

Controversy on Medication Coverage – “step therapy” (also known as “fail first”)

04/22/2009 — Nancy Sajben MD

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Insurance Industry Opposes Physician’s Choice of Medication for Pain Relief

The best or just the cheapest?

Before I define “step therapy,” let me introduce Forgrace.org, a nonprofit organization “Dedicated to Ensuring the Ethical and Equal Treatment of All Women in Pain.”   Based in Los Angeles, the organization was formed in 2002 by John Garrett, Executive Director, and his partner Cynthia Toussaint, an accomplished ballerina who has suffered with CRPS (and later fibromyalgia) for 26 years. Thanks to their leadership advocating for health care reform in California, today they announce that

For Grace and HAAF’s bill, AB 1144, was heard by the California Assembly Health Committee in Sacramento yesterday (April 21) and it passed overwhelmingly with a vote of 14-2.  There was strong opposition from the health insurance industry – and this effort will be an uphill climb as we move the bill along to the Senate.

Also, today, ABC News national covered the issue of “step-therapy” (also known as “fail first”) along with our bill, that if signed by Gov. Schwarzenegger, will abolish this unethical prescription practice that negatively impacts women in pain.  Ms. Toussaint pitched this story, consulted and interviewed for it.

Because of its importance to every single one of my patients whose lives hang by the constant threat of an indifferent refusal by insurance carriers to continue providing medication that they require, I am posting almost the entire ABC News article titled “Patients Irate With Insurers’ ‘Fail First’ Policy“ by Dan Childs

What Is Step Therapy?

The basic idea behind step therapy is to start with the most cost-effective and safest treatment, progressing to more costly or risky therapy only if the current treatment is not effective. In theory, proponents say, the strategy both minimizes risks to the patient and keeps overall costs under control.

Robert Zirkelbach, spokesman for America’s Health Insurance Plans, said that when it comes to the bigger picture, step therapy is a key element in making the country’s health care system more efficient by creating a standard system of care from state to state. He said that this saves costs, and it also ensures that patients get access to therapies that have been proved to be medically effective.

“We see individuals with the exact same illnesses get drastically different treatment depending on where they live,” he said. “Right now there is no correlation between the money being spent and the health outcomes being advanced. Our goal is to help guide the patient.”

Dr. Forest Tennant, head of the Veract Intractable Pain Clinic and editor of the trade magazine Practical Pain Management, is also Cook’s doctor. He agreed that in theory, step therapy is not a bad strategy. And he added that doctors have traditionally employed a form of step therapy, in which they would gradually increase the dose of a given medication for a patient who was not responding until they were able to achieve the desired effect.

Doctors Employ Different ‘Step Therapy’

And even when it comes to designing a course of treatment, Tennant agreed that a cheaper approach is preferable, as long as it works for the patient.

“Given the cost of some of the medications I prescribe, I also want the patient to try the cheaper medication first.”

But he said that the step therapy used by the health insurance industry is different in that it may actually place a preferred therapy out of reach of a patient. Particularly vulnerable may be pain patients like Cook and Toussaint, who have experienced success with a given medication but are switched to a different drug by an insurer.

“What we have today is a situation where a patient is knocked around in the system, usually after they’ve already tried something that works for them but which they can’t have,” he said. “All of a sudden, the drug that they have been taking for quite some time is pulled away from them — because it is more expensive, usually.

The Best — or Just the Cheapest?

According to data collected in 2006 by the health care analytics company Verispan, the drugs for which step therapy is most commonly used are anti-ulcer medications, with 58 percent of health insurance plans using step therapy for this class. The data also reveal that antidepressants are the fourth most common drugs subject to step therapy, with 45 percent of plans subjecting these to step therapy. Twenty-six percent of plans use step therapy for pain drugs, according to Verispan, and other drugs including heart medications and antipsychotics are also on the list.

Zirkelbach argued that in most cases, patients are allowed to switch drugs if the recommended option is not working for them, and if the drug that the patient is switching to is supported by medical evidence.

“If there is a good medical reason to switch to drug A versus drug B, health plans typically allow that to happen,” he said.

But he noted that how long a patient is required to stay on a given medication before making a switch varies from case to case. Doctors who prescribe a drug that is unapproved by the insurance company risk receiving what Tennant calls a “tantrum letter” from insurance companies.

“The insurance companies hire auditing firms, and they demand to know why I prescribe [patients] certain drugs,” he said.

The net effect, Tennant said, is a grave imposition on the doctor-patient relationship.

“I have to say [to patients], ‘I can’t tell you what you should take. I can only get you to get what your insurance can pay for, and I’ll design a regimen,’” he said. “For the expensive medicine, the doctor no longer chooses what he wants.”

And according to a Thomson Reuters study published in the February issue of The American Journal of Managed Care, step therapy may actually be more expensive for insurance companies, at least when it comes to patients receiving medication for high blood pressure.

Step Therapy May Not Be Cheaper

In the study, which was sponsored by Pfizer, researchers looked at insurance claims for 11,851 people with employer-sponsored health coverage that incorporated a step therapy protocol for high blood pressure drugs. These patients’ claims were compared with those of 30,882 patients on similar medication who did not participate in a step therapy program.

What the researchers found was that the group of patients treated for hypertension under the step therapy program had 3.1 percent lower drug costs. But these savings appear to have been wiped out by the apparent increase in hospital admissions and emergency room visits. Over two years, the step therapy patients incurred $99 more in healthcare costs per quarter, on average, than the control group.

Hope for Step Therapy?

If indeed California passes anti-step therapy legislation, it would not be the first to do so. New Jersey already prohibits such plans. And even the Centers for Medicare and Medicaid Services may be considering regulations to limit step therapy by health plans available to Medicare patients.

But Robert Taketomo, president and CEO of the Glendale, Calif.-based managed care contracting services organization Ventegra, warned that if such legislation passed in the state, patients may find that other parts of their coverage will be cut back to compensate.

“As long as healthcare is a benefit, and not a right, then measures such as step therapy are important means of preserving pharmacy benefits,” he said. “If step therapy were to be prohibited through legislative means, there are other means through which a payor — whether they be government, health insurer or employer — could limit their cost exposure in pharmacy.

“These could include removal from formulary, increases in copayment, addition of deductibles (and increasing them), or ‘carving out’ pharmacy altogether and just cover medical expenses.”

Tennant said he believes the true solution to the problem does not lie with new laws.

“There has to be some goodwill meeting of the minds for the people who practice medicine, those who need the help, and the people who are paying for it,” he said. “Most of the [insurance companies] are trying to develop formularies comprehensive enough to get the job done without compromising patient care too much.”

But Cook said that as long as her insurance adheres to a step therapy policy, she and other pain patients will worry about her medication one day becoming unaffordable.

“We all know that our lives could change at a moment’s notice if the insurance companies say, ‘Change,’” she said.

To view some of Ms. Toussaint’s presentation to the media, including her “fail first” experiences… on the second page of their “Videos” go here.

Her focus has now shifted to bringing a single-payer, universal health care plan to all in California which will provide a model for the rest of the country.

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

Posted in Controversy, Insurance, Politics of Pain. Tags: , , . Leave a Comment »
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