A Systems Approach To Understanding Insurers' Policies

United Healthcare's Prescription Solutions raised the price of Medicare Part D ezetimibe from approximately $75 in 2008 to approximately $250 in 2009. Unfortunately, because I had already signed up to renew my coverage, before the 2009 formulary with its new stratospheric charges appeared in my mailbox, I had two choices: stop this LDL lowering drug or pay up.

Thinking about this from a systems perspective, I could envision United Healthcare - which the NY Times reported on 1/16/2009 had settled ". . . class-action lawsuits claiming it had underpaid patients and doctors . . . ." doing this for any of several reasons. First, perhaps the price of ezetimibe had tripled, but I wasn't aware that it had. Second, perhaps those taking ezetimibe are a high risk group, and if the United Healthcare's Prescription Solutions did not make available the drug these people needed at an affordable price, they might leave (reducing United Healthcare's MediGap and other coverage risks and Prescription Solution's Risk in a variant cherry-picking arrangement). Third, perhaps Prescription Solutions was using patients treated with ezetimibe as battering rams in negotiating prices with drug manufacturers.

By the way, on January 8, 2009, the FDA concluded that those high risk individuals taking a lipid lowering combination including ezetimibe should not stop taking the medication. . Perhaps United Healthcare was just too busy defending its class action cases and investigations by various state attorney generals to have paid attention to this warning and price its Zetia accordingly.

How To Destroy Medicare!

I met with a group of physicians today who told me that when a transition from one Medicare fiscal intermediary (let's call it "NH") to another (which we can call "Palm")occurred in 2008 in Santa Clara County that they had no Medicare payments for 5 months. Not only were their incomes reduced to a trickle, they had to borrow money to stay in practice.

How many physicians, with this type of experience, will allow themselves to become more dependent on Medicare patients? Was this just an episode of incompetence, or a callous effort to move Medicare beneficiaries from standard Medicare to Medicare-HMOs?

Whatever it was, it bodes poorly for Medicare patients. And it speaks volumes about the Medicare bureaucracy.

The HIPAA Privacy Rule and Health Information Technology - NEW!

OCR has published new HIPAA Privacy Rule guidance documents as part of a Privacy and Security Toolkit to implement The Nationwide Privacy and Security Framework for Electronic Exchange of Individually Identifiable Health Information (Privacy and Security Framework). These new guidance documents discuss how the Privacy Rule can facilitate the electronic exchange of health information. Clicking on this blog's title should connect you with this site.

Do It Now

Reading the pronouncements from President-Elect Obama and Mr. Daschle, you wouldn't think that health care reform is an emergent need. There's money for the auto industry, the banks, the brokerages, and perhaps the roads and bridges, but little understanding that for sick children, their sick parents, and many of our working uninsured sick, we have run out of time. Mr. Obama, a child with leukemia needs access to, and provision of, health care without regard to insurance coverage. A sick parent, whose illness jeopardizes employment and the family's financial well-being, and who is one paycheck (or less) from being homeless, can't wait two years for help. A senior who is in the donut hole and finds herself unable to spend the $254 it will take to get 90 days' worth of medicine from the Prescription Solutions (AARP) provider, may be dead before more help is on the way.

It takes guts to do what's right, to provide the health care services that many Americans desperately need. In two years, many of those who could have been helped will be dead or be suffering from chronic disabling disease that could have been addressed on a timely basis if only the resources were made available now. Unfortunately, there was no one at the table honestly, and without a conflict of interests, representing those in need, offsetting the hospital industry, the insurance industry, the durable medical equipment providers, those who are promising health record vaporware, the associations of those who are addicted to feeding from the federal cash flow, and those who simply don't believe that the uninsured are worthy of help.

There simply isn't time to waste. Do it now. Fix our broken health care system.

A Tale of Two Companies

In a recent blog, I described problems with one highly advertised diabetic supply company which I did not name because my policy is to praise in public and criticize privately.

In contrast, today's blog describes the straightforward and appropriate response which I received from Liberty Medical Supply's COO. A refreshing no-nonsense letter, strikingly different from the other company's responses. And because of the difficulties I experienced, without hesitation Liberty offered (and I accepted) to provide me with Accu-Chek lancets, a clearly superior product.

Here is Liberty's Chief Operating Officer response to my letter criticising Liberty's "generic" lancets:

"Dear Dr. Kaplan,
Thank you for your thoughtful letter regarding Liberty and One Touch lancets. You bring up a valid point regarding the comfort levels provided by different lancets, and I wanted to reply to you personally.

"To give you some background, over the past six months, all Liberty lancets have been moved from 28 gauge to 30 gauge, compared to One Touch lancets, which are 25 gauge.

"For you, and all patients with diabetes, finding the least painful method of obtaining a blood sample is crucial. I am sorry that you were not pleased with Liberty's lancets.

"As of this date, Liberty's lancet manufacturer is complying with our instruction to install new molds, which should eliminate the plastic problem and the slight bend that can occur on the shaft when the plastic cap is twisted off. Also, the new needles have a tri-beveled and electro-polished finish to improve the discomfort of finger sticking. And finally, by May 2009, all Liberty lancets will be made on fully robotic systems that will significantly tighten tolerance levels and quality in lancet manufacturing.

"At Liberty, we understand the importance of lancets in managing diabetes and we are
constantly looking to improve upon the products we offer, Again, Dr. Kaplan, thank you for contacting us. If I can be of further assistance, do not hesitate to contact me directly at 772-398-5822.

Sincerely,
Keith W. Jones
Chief Operatlng Officer
Liberty Medical Supply, Inc."

Liberty Medical

Will Your Health Information Be Secure?

Today, President-Elect Obama announced his goal of having all medical records computerized in five years.

Approximately 10 days ago, a team (Alexander Sotirov, Marc Stevens,
Jacob Appelbaum, Arjen Lenstra, David Molnar, Dag Arne Osvik, Benne de Weger) "...identified a vulnerability in the Internet Public Key Infrastructure (PKI) used to issue digital certificates for secure websites. As a proof of concept we executed a practical attack scenario and successfully created a rogue Certification Authority (CA) certificate trusted by all common web browsers. This certificate allows us to impersonate any website on the Internet, including banking and e-commerce sites secured using the HTTPS protocol." http://www.win.tue.nl/hashclash/rogue-ca/

Because access is not assured secure, computer medical records, which hold your and my highly personal and sensitive information, are not secure. A team has documented its ability to break a major security system used by financial agencies. Hackers will be attracted to the new challenge of computerized medical records like maggots to old meat.

Medicare's Policy Concerning Diabetic Supplies

Letter from Noridian Administrative Services LLC (Medicare Fiscal Intermediary) in response to my letter [see blog Jan. 5, 2009] Again, I have redacted certain information.:

The Centers for Medicare and Medicaid Services has asked that I respond to your inquiry regarding the generic diabetic supplies that you had received through ______ Pharmacy Service/_________.

"Medicare does not differentiate between generic and name brand diabetic supplies. As long as the Statistical Analysis Durable Medicare Equipment Regional Carrier (SADMERC) has approved the ________ lancet device and lancets, then they can bill them to Medicare using HCPC A4258 and A4259. Payments for these supplies are the same whether they are name brand or generic.

" ______ corporate policy is to provide generic products such as lancets/lancing devices to new patients. ______ should be more forthcoming with this type of information and hopefully with your feedback they will be more open with new patients regarding this policy.

If you have additional questions on Medicare coverage, you may contact the Centers for Medicare & Medicaid Services Customer Service Center at 1-800-MEDICARE (1-800-633-4227).
Sincerely