I was watching Mad Money the other day and Cramer was interviewing some guy who was talking about Medco, which, I gathered as the talk progressed, is a "Part D" insurance plan. Part D plans, for readers who don't know, are the Medicare insurance plans for prescription drugs. There are a lot of them - 55 in this region, this year. Each year everyone has to go reassess their Part D plan, because each year all the plans have permission to change their formularies and their reimbursement rates and if you just stay with the one you liked last year, you're likely to find that this year, your life-saving medication now costs $600 a month...and you can't change until the next "open enrollment" period a year from now.
The reason why Medco was doing so well, this guy was saying, was that Medco "knows the protocol" for complex health conditions - it knows just what medications someone with a "complex" problem should be taking. Since it knows this, it can make sure that the patient is taking the right medications (by denying payment for the wrong ones) and this saves the company money. Lots of money, apparently. It was a strong "buy", according to Cramer - great profit margin, dividends flowing and all that -lots of folks making nice returns on your complex health condition.
Hmm. Since I work in a community mental health organization, I have occasion to be involved with many persons who have "complex" health conditions that require lots of medication. And since my role in that organization involves "benefits", I see a lot of "Part D" plans one way and another. What happens in the actual world when "complex health conditions" meet Part D plans is this: the Doctor prescribes a medication; the patient tries to get it at the pharmacy and is told that his Part D plan won't pay for it without "prior authorization"; and then the nurses spend a couple of hours filling out forms in an attempt to get the Part D insurer to pay for the medication the Doctor prescribed. Sometimes they get it, sometimes they don't. Without the authorization, the drug costs way too much for the patient to take it, and that's that. The Nurses wish those darned Doctors could memorize the various Part D formularies and save everyone a whole lot of trouble.
So when I heard this guy on Mad Money describing how much money Medco is making by only authorizing the drug regimen they approve, and not paying for other combinations or quantities of medications, I had another (yes! Another!) great idea! Clearly, we do not need Doctors to be prescribing anything! Insurance companies already know what you should be taking for your complex condition - all they need from the Doctor is the diagnosis! After that, the insurance company can take over! They'll tell you what you can take! Isn't that great?! Think of the savings! Doctors will only need to learn diagnostic skills! Once the diagnosis is made, the appropriate medications follow automatically! This is so great - talk about cutting down on medical errors resulting from bad handwriting! There will BE no bad handwriting! There will be no prescribing!
The Doctor can just provide you with a card imprinted with your particular diagnosis, which you take to the pharmacy, which then dispenses the correct (according to the insurance company) drugs in the correct dosages and off you go! You'll have something like an 87% chance you're getting the right stuff, since their studies show that 87% of persons with that diagnosis should do well on their designated combination. Talk about efficiency!!
I can see the day when Doctors will be really "extras" that no right minded insurance company will pay for at all. Soon, patients will be able to just 'click the boxes' next to their symptoms at their "virtual Doctor" website, the computer program will provide the diagnosis, allow you to print out the diagnosis card on the spot - and you can take that to your pharmacist who will give you what your insurer will pay for! It's beautiful! It's almost what Kaiser has now.
It could be the next evolution of the digital health records project! If we do it right, none of us may ever need to see a Doctor again - when our digital record indicates that we are having a "medical condition", perhaps our insurance company can just send us the right medications automatically...this could cut down on the number of Pharmacists, too! Think of the savings! Think of the stock returns!
Don't you love "for profit" healthcare?! I know I do.
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6 comments:
Heard a sw on the assaultive unit not doin her job. Those poor patients-no wonder they never move. Worse still no consequences have been dished out. This sw is still there!!! looks like its more conducive to treatment to read People magazine than to pick up the phone and find placements. Once again, just when u thought the Forts standards couldnt get any lower.....Why has nothing been done! This is unethical.
Oh for gosh sakes - can't you guys just say what the heck happened???
I have no idea from this comment what the problem is, except the social workers are still as lame as they were when I was there!! Tell the gd'd story!!! Who cares, if you don't????
Get some b____s.!
g.f.
This SW was not even calling on placements for her caseload when she told people she was. maybe a couple of those on her caseload were acted upon, but the others-nothing was being done while they were being warehaoused and apparently meeting minimal expectations for safe behavior. in the meantime, the patients would grow frustrated, until they escalated and the window of opportunity waned. In the meantime, the SW stated she was looking for placements for the pateient, but after further reasearch, these claims proved untrue. Some of those patients are still there after 5-6 years at the most.
OK! Much better! And, Yes!, totally....I've seen this phenomenon again and again...professional laziness. I agree, the offender should be fired. These are the very people that cause the citizens of the state to feel that their tax money is wasted...and the citizens are right! Fire them! Require real performance and make it possible!! When I worked there, the policy was to require non-performance. I believed this requirement came from the top - and I advocated for change at the top...to no avail, sadly.
g.f.
Perhaps JCHO should be notified. This is ultimatly patient abuse and at the bare minimum abuse of a person in trust. Any other enties that should be notified? Again, this practice went on for years with select patients, and is still occuring. I doubt the power structure would like to remoce the rug they swept this under and expose it-or they would have already. i work out at the Fort and have never seen such abuse at this level. I know SW `s have a bad rep, but this case takes the cake. That assaultive team pretends nothing is wrong, that all is ok. What is wrong with that? This has all been recently uncovered in the last 4-5 months. All the more reason to take action now. Obvously the pateint advocate either is indifferent, or does not know what is occuring. Very, very, disturbing.
again, this did happen on the assaultive unit. Snyone from there got any addditional info that could help the cause??? Cmon people, step up.
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