Monday, November 24, 2014

The State of Health Care: Two Riveting HMO Part D Epics

Part D Is What We Got,
So, Part D Is What We'll Use
A great opportunity for the old and sick to trot 
out the flag of their American "can do" spirit

When the sold out Republicans finally got enough Senators to pass Part D -- with Dick Cheney's 3 AM tie breaking vote as then Senate President -- they had already packed the poor bill with plenty of mischief. MeanMesa isn't sure whether there were 100's of Big Pharma lobbyists in the Senate Chamber with them or if there were just little, barely visible headsets plugged into all those old grey haired white guys to deliver their orders.

Not surprisingly, all these old reprobates, under Dick Cheney's "spiritual leadership," of course, ultimately "created Part D in their own image." Naturally, the final product was not only an embarrassingly awkward sell out to Big Pharma, but also grotesque in a manner of other ways, too.

This blog has posted plenty about both Part D's savage process and its weird product in the past, so there's little reason to "dig up old skulls" right here just because we might need some pistol targets. However, for Short Current Essay visitors who may happen to be relying on Medicare and Part D for health care now, and for those visitors who, thinking ahead to when they, too, will be in this crowd, are already interested in the "moving parts" of the monstrosity, MeanMesa will share a couple of fascinating first hand experiences in this post.

Now, at some point perhaps you have overheard a couple of old men complaining to each other endlessly about their health problems -- and probably about their doctors, too. This post has just a little of this, but, hopefully, just enough to "frame" the real issue being presented here.

That "real issue" has to do with attempting to "do business" with the tormented, convoluted disaster which was left in the old Part D legislation when Dick Cheney and his pack of trained Republicans had finally finished dissecting it for the salivating pharmaceutical company and corporate insurance lobbyists waiting for them in the hall way outside the Senate Chamber.

What the same crowd did to the Affordable Care Act didn't help much, either.

Here are a couple of true tales -- nothing particularly outrageous, alarming, provocative or even revelatory -- which "paint the picture" of what's still going on now as every day Americans try to shoe horn the bizarre rules of these benefits into something they can afford.

Riveting Medicare Epic Number One
Androgel and Part D

Now, when we touch on testosterone therapy, many of us immediately flood our "mind picture" with the image of a sun glasses bedecked, rotund fifty year old sporting an open chested hula shirt and gold chain trying frantically to outrun his "mid-life crisis" in his red Corvette Sting Ray convertible. 

Although that probably happens often enough, in the case of MeanMesa we see an ancient Social Security guy with "abnormal kidney function" and a few other geriatric maladies who doesn't even own a car. You know, even if MeanMesa did still own a car, that "mid-life crisis" is now already so many years in the past that it would no longer be visible in the rear view mirror.

Well, one of things that a good endocrinologist prescribes for old guys like MeanMesa is testosterone therapy. It makes all the difference in the world. Some of the benefits are not getting obese, having enough energy to still move around quite a bit [MeanMesa likes lots of fresh air, good healthy food, sunshine, gardening and bike riding...], and keeping a fairly sharp mind instead of drifting into the common, foggy "old folks home" territory.

However, even with the possibility of using this modern medicine, a "fly still lands in the ointment," more specifically, a "Part D fly lands in the Androgel ointment" The "fly" amounts to the conflict between the price of the Androgel and Part D's "doughnut hole."

Androgel costs roughly $300 per month. A little arithmetic extends that to around $3,600 per year -- or about $1,000 more than the maximum coverage offered before Part D dumps one into the doughnut hole. For years, MeanMesa has bought the Androgel monthly -- along with everything else -- until the doughnut hole hit, then quit -- the Androgel and most everything else, usually around September or October. 

This turned MeanMesa's Part D "insurance coverage" into a "nine month policy." After it, quite dependably, routinely "cratered" every year, the last three months went ahead on a no coverage "cash basis." Since there was almost never enough extra cash for a "cash basis," this meant cutting back on prescriptions and toughing it out until the next January when Part D came back.

Well, this year MeanMesa had simply had enough, and that meant that it was high time to do some serious geriatric complaining. All of that sound and fury pretty much went no where until it finally reached a little known agency of MeanMesa's massive HMO called "Medication Management." That guy actually called back, and he had a plan!

It was clear that he was serious. He spoke with the troubling, inauthentic, forced enunciation -- frequently interspersed with kindly expressed, condescending inquiries as to whether his words were "understood." A, shall we say, "experienced" senior such as MeanMesa right away spotted as a young man's very best effort at sincerely communicating.

Here is the content of the "follow up" letter he sent a day later.
MeanMesa's letter from Medication Management Systems

Well, aside from a monthly encounter with alternating bruises on corresponding sides of MeanMesa's gluteus maximae, the new plan was rolling along "roses, simply roses," until the particular event occurred which was to become the very "essence kernel" ultimately inspiring this part of the post.

What the contractor from Medication Management Systems offered was, in fact, the case. Right away, the $300 per month cost of Androgel which had been draining MeanMesa's Part D coverage, ceased! The cost of the injections, because they were being administered by a very nice nurse in the Pres. [Presbyterian Senior Care -- a non-profit, HMO Medicare provider] doctor's office, now became a Medicare Part B expense, and, as such, they were covered without brutally pounding MeanMesa's Part D coverage into the doughnut hole.

There wasn't even a co-pay required because she was a nurse -- not a doctor!

The very interesting "particular event" appeared a couple of weeks later. A thoroughly mechanical, automated system used by Pres. to "recover" little bits of billing from here and there which might have otherwise "slipped through the holes," detected a "balance due" hidden deep in the depths of all this clever Medicare maneuvering.

No doubt only a few mere seconds later this dedicated little piece of software had dispatched a letter with a 40 cent postage to MeanMesa warning that a bill might soon be issued to collect this balance due. The "business end" of that letter is posted below.

Amount billed: $4.97 / Amount allowed: $4.47 / Amount postage: $0.40

This is NOT a bill -- just a WARNING

 Clearly, the "monster" is after the fifty cents.

None of this should be considered a complaint on MeanMesa's part. Medicare has in the past - and is currently -- keeping this old bird alive to keep pounding out on this blog. However, all this is posted here to illuminate the almost insane contortions the program has to routinely make in order to fulfil "the letter of the law."

There may be all manner of minor little "things" about Presbyterian which can be quite irritating, but what is shown here comes directly from the Federal Medicare program.

Bear this example in mind if you ever need to defend the "single payer" proposal that Big Pharma slaughtered in the "debates." The sold out GOP dumped the "single payer" idea for a policy that runs like this.

 Riveting Medicare Epic Number Two
Treating the Gout with Part D

So, having decided to "open the sleeping robe" to show two things normally obscured by what are widely considered contemporary "good manners or social protocol," MeanMesa has led with the "expose'" with the brasher of the two revelations, that is, the testosterone therapy, and now follows up with the slightly less awkward issue of the two, that is, the gout.

Happily, although the point of the arising for these old bones was deep in the SW Kansas Bible belt, they were never, subsequently, infested by very much of the irritating common malady which is commonly called "false modesty."

The gout has suffered an onslaught of cultural ridicule -- particularly as a cinematic script mechanism, often portraying it comedically as one of "the wages of sin" for individuals with an appetite to eat and drink in excess. Before the first camera was invented, it was tacitly accepted as one of the perils -- and retribution -- for being a member of the nobility or simply over indulging the in the "pleasures" of wealth as viewed by the poor.

Ollie has the gout - Them Thar Hills 1934 [source: image and quote]
Ollie has a severe case of gout and is ordered by his doctor (Gilbert) to take a vacation up into the mountains to get some fresh air and relax. Of course Stan comes along to make sure that he receives neither!
Doctor: "That's the worst case of gout I've ever seen"
Ollie: "What causes that, doctor?"
Doctor: "Too much high living"
Stan: "Well maybe we should move down into the basement"

MeanMesa first encountered the gout a year or so ago. Although not life threatening, the frighteningly painful experience was, well, shocking. The first time through it, the decision was taken to employ every "urban myth" and "old wives' tale" remedy -- an agonizing mistake. Since then, at the first whimper of symptoms MeanMesa heads straight for the doctor.

This brings us to the second "epic" Part D story in this post. It actually has almost nothing to do with the gout, and it has almost everything to do with Part D.

MeanMesa has episodes of gout because of "abnormal kidney function." That's the phrase a Medicare nephrologist will use to "kindly" tell a patient that "You are probably going to die from kidney failure, but just not particularly soon."

The second time MeanMesa had gout, the trip to the doctor worked wonders. It was "classical gout" -- meaning that it was in a foot, and the Doctor's prescription, Prednisone, literally ended the blinding pain by the next morning and completely knocked out most of the swelling in two days.

However, the next time the gout attacked MeanMesa's right elbow. In no time it was a "screaming pain factory," but it was not recognized as gout! It wasn't in a foot! Although there was a fresh, full prescription of Prednisone stored away in the medicine cabinet for just such an outbreak, MeanMesa didn't "connect the dots."

So, predictably, MeanMesa headed for the Doctor again. The elbow was the size of a grapefruit. Here's where the story gets interesting.

The Doctor carefully examined the elbow, even taking iPhone photos of the swelling with a little measuring tape laid along the offending arm. Then, he prescribed Prednisone. Except, for convenience, he prescribed Prednisone in what is called a "medi-pack."

Prednisone in a pharmacy vial and Prednisone in a "medi-pack"
The "very convenient" $10 "medi-pack"

The Doctor probably thought the "medi-pack" idea was a good one because he wanted MeanMesa to take five of the little Prednisones the first day, four the second day, three the third day, and so on for five days. This was not MeanMesa's usual Doctor, and more than likely, he was being more cautious in insuring that his medication protocol would be followed.

MeanMesa's usual Doctor would have been quite aware that MeanMesa has a degree in mathematics and is, consequently, capable of handling such a dosing regime with the 20 mg tablets he prescribed.

The "medi-pack" contained 21 foil wrapped, 4 mg doses of Prednisone. It cost $10.

The pharmacy vial contained 20 lose tablets of 20 mg each. It cost $1.66. 

Further, both that $1.66 price and the $10 price had no part paid by Part D because MeanMesa is in the doughnut hole [thanks to the Androgel...]. Both prescriptions were filled with generic pharmaceuticals.

Wait! You might say. The "problems" with Medicare and Part D deal with hundreds of billions of dollars. This example is describing a difference of only $8.34!

Yes, but...

Tens of millions of American Seniors are navigating through this thing every day. In plenty of cases the "difference" is incredibly greater than $8.34!

Hundreds of thousands of elderly men are wrecking their Part D coverage every year with medications like Androgel prescriptions because they -- like MeanMesa -- had never heard of a "Medication Management System" available in their HMO.

What in the hell are we doing? Why is a health insurance company writing a letter to warn that someone may be getting a bill for $0.50 sometime soon?

Why are we making all of this so incredibly hard and so incredibly expensive?

These are two pharmaceuticals being used by one guy. Scaled up to the national size, this is insanity.


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