Monday, May 25, 2009

Medical Rationing Details

How Will Medical Rationing Occur?
05/24/09 - MDOD by 911DOC

Dr. JN is a board certified Neurologist dealing with a flunky to get an MRI imaging test approved.

[edited] A 44 year old Rwandan woman with controlled HIV developed back pain with radiation down both legs. Bed rest and Advil don't work.

MRI Rejected by Medicaid "Not enough documentation, does not meet criteria". Call the MD line. Dr. X calls back, claims that he is a neurologist. "You're just too lazy to prescribe Advil, is that it? Or maybe you're just a chickenshit who doesn't want to get sued. You know it's nothing". Refused.

In 33 years out of school, no one has ever talked to me like that, least of all another physician.

Resubmitted with extensive documentation of infection risk in African patients with poor cellular immunity. Rejected.

Called again. Now they say, if I send her to a specialist and the specialist orders the MRI they'll do it. I AM a specialist.

5 weeks later, it's approved and finds a big spinal abscess, likely TB, cultures pending.

Can I Get Prior-Authorization To Kick Your Ass?
04/29/09 - MDOD by Lofty Zahari

[edited] Let me tell you how it usually goes when I try to get a wonderful, newer drug approved for my patients. I love Byetta and prescribe a ton of it. It is the only commonly-used drug for type 2 diabetes that lowers glucose AND helps patients lose weight. It often requires pre-approval from insurance carriers.

Dr. Lofty: Hi, I'm calling to get prior approval for Byetta for my patient.

CSR: And your question is?

Dr. Lofty: My question is, what information do you need to get this drug approved for my patient?

CSR: Yes (looks up questions to ask under 'Byetta protocol'). So, why does this patient need Byetta?

Dr. Lofty: Because they have gained 20 pounds over the past year on Actos and glyburide and in my experience I can get this patient's hemoglobin A1c down about 1% with about 20 pounds of weight loss using Byetta, and get them off of these other drugs.

CSR: I see. And what is the medical justification?

Dr. Lofty: I just told you the medical justification.

CSR: Yes, well, I'll need to fax over a two-page prior authorization form that will need to be filled out completely along with the last three chart notes documenting failure to achieve control with....

[Now, into the TWILIGHT ZONE, where we are magically free of social convention and can say what we wished we could say to one another ... ]

Dr. Lofty: Hey f---head with your G.E.D. diploma hanging on your cubicle wall, I went to f---ing medical school for four years, did three years of residency training plus a chief resident year, and have been practicing diabetes almost exclusively for ten years. My experience tells me this patient needs Byetta and I want him to have it NOW! Losing weight and shrinking the waist probably reduces cardiovascular risk in patients with type 2 diabetes.

CSR: Sir, we really don't give a flying f--- if your patient loses weight. We would prefer he or she remain on the cheaper, generic drugs that they are currently taking.

Dr. Lofty: Well, the patient sure would feel better in the long run losing twenty pounds and losing about 2 gallons of fluid from his legs.

CSR: Again, don't give a shit about this patient's quality of life. Too expensive to use this drug. This person won't be on our plan in two years, so we could give a rat's ass whether or not they lose weight or feel better. They'll be someone else's problem in two years.

Lateral Boomerangs
05/24/09 - Throckmorton's Other Signs by Throckmorton

Medicare makes the rules and people play the rules.

[edited] Medicare has a whole bunch of diagnoses that it will not pay for if a patient is discharged and readmitted within a short period of time. Nursing homes and extended care facilities are decreasing in number and want nothing to do with complicated patients, because of lawsuits and threats of lawsuits. Home care is the only option for patients that do no meet Medicare admission criteria and can't get into an extended care faclility. So, many go home and then need to be re-admitted.

The practical answer is to re-admit them at another hospital. A so-called "lateral".

A lot of folks went away for the holiday weekend, so they took grandma to the hospital! She was there 2 weeks ago for COPD breathing problems. The ER must admit her, but then the shell game starts to do the "lateral". Welcome to the world of federally managed healthcare.

+ + + + +

Why Test? You Are Already in the Hospital
It seems that Medicare wants to cut down on unneeded testing. The answer: Don't give the test at all if the patient is in the hospital. That will do it!

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