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by: Theresa Flaherty - Tuesday, December 8, 2009

It's been just over a year since Medicare's new compliance requirements went into effect for CPAP. Over the past year, I have checked in regularly with CPAP providers to see how its going. For the most part, providers take the good with the bad and simply try to take care of patients. However, I never fail to be amazed at the disconnect between Medicare/physicians/beneficiaries, with the provider stuck firmly in the middle.
Kelly Riley, director of the MED Group's National Respiratory Network forwarded me this latest example from a provider:
We have had patients that have not been compliant at the end of the 91 days. When presented with the available options at the end of the trial period we have had a local pulmonologist tell us that if we picked up the patient's equipment (they were unwilling to order a new sleep study, DC or change the patient to bilevel) that … we would never receive another referral from them again and become "blacklisted".  They did not care what the Medicare rules were. Keep in mind that the patient is unwilling to sign an ABN and refused to voluntarily return the equipment because she says the Dr wants her to have it. This is putting the dealer in a catch 22 situation.  Can we get guidance from the Medical directors on what to do when this happens?  I believe there needs to be some recourse to the physician in a case like this.
This provider raises some good points. Is it fair for physicians to, essentially, threaten providers with blacklisting? Is it legal for a beneficiary to hold CPAP equipment hostage? Isn't that ... stealing?

Providers, what else are you experiencing?

Theresa Flaherty

by: Theresa Flaherty - Monday, December 7, 2009

We hear a  lot about industry efforts to repeal competitive bidding, the oxygen cap, etc. But another effort continues to chug quietly along: getting Medicare to cover home infusion therapy. The most recent effort, The Medicare Home Infusion Therapy Coverage Act, continues to gain sponsors.

It's not the first time the issue has come to the table, but industry stakeholders hope this time they achieve their goal. With all the focus on cost savings to the health care system, the home infusion message should be a winner, but it's hard to get lawmakers to understand that at times, says provider Kevin Nestrick, owner and founder of Altius.

"We've gotten very close but we can't seem to get them over the hump," he told me recently. "It would be a tremendous savings to Medicare but they don't (see) that."

The average cost to provide infusion therapy per day: $200 in the home; $300 in a skilled nursing facility (SNF); and $1,200 in a hospital, according to the National Home Infusion Association.

As of Dec. 1 32 senators and 102 representatives have signed onto the bills (S. 254 and H.R. 574). To see if your lawmaker has done the right thing, go here for a list.

Theresa Flaherty

by: Theresa Flaherty - Friday, December 4, 2009

CMS is circulating a reminder to pharmacists: If  you're not accredited, your time is almost up. In October, the deadline for accreditation was pushed to Jan. 1, 2010. We've seen a flurry of announcements in recent weeks from pharmacies who just received accreditation—those are the folks lawmakers and industry stakeholders had in mind when crafting the extension.

In the meantime, current health care reform includes a permanent exemption for pharmacies that bill Medicare for less than 5% of their DME revenues.

But pharmacists shouldn't wait around to see if that passes. The road to health care reform promises to be a long haul and there are no guarantees that pharmacists will ultimately escape accreditation.

And, don't forget about those surety bonds!

Theresa Flaherty

by: Theresa Flaherty - Thursday, December 3, 2009

This is kind of cool.

The Reggie White Sleep Disorders Research and Education Foundation has developed a free iPhone application that enables users to determine if they are at risk for obstructive sleep apnea. The "app," Sleep Well, combines three screening tools used by sleep specialists to determine an individual's risk of having or developing the sleep apnea.

The app also includes a feature that will list nearby sleep disorders centers for users. iPhone users can get the app at http://appshopper.com/healthcare-fitness/sleep-well.

Theresa Flaherty

by: Theresa Flaherty - Monday, November 30, 2009

There was a reader essay in my local Maine Sunday paper yesterday: a goodbye to a "much-loved" cat. The cat, a 16-year-old Siamese, was diagnosed with pancreatic cancer.

From diagnosis to death: a visit to the emergency vet; an ultrasound to reveal a grapefruit-sized tumor; a visit to a pet ultrasound specialist in New Hampshire; a visit to a veterinary cancer surgeon in Boston; scripts for kitty painkillers and appetite stimulants; a visit to a local veterinary cancer specialist; a holistic veterinarian acupuncturist; and finally a home visiting vet to put the poor thing to sleep—the cat, not its owner.

The cat, old and terminal (it's pancreatic cancer, for crying out loud) was hauled around New England in search of a happy ending that was never going to happen. Granted, it's the owner's right to spend her time and money on her pet however she wants, but honestly. Accept the inevitable already.

When it comes to people, I think many of us do the same thing. On 60 Minutes a few weeks ago there was a story about how patients, their families and the medical establishment just refuse to let people die. And, while those folks are in the process of trying not to die, they are subjected to numerous procedures, tests and specialists. I don't mean to sound heartless, but what a waste of money!

Earlier this year, there was a great hue and cry over "death panels." But, in the health care reform debate, there needs to be an honest discussion about when to let go. It helps no one to prolong pain and suffering and it certainly needs to be considered when talking about taxpayer dollars. Death happens everyday in the private insurance sector as well as for the uninsured. There's no reason the Medicare/Medicaid populations should get a reprieve.

If we are going to extend health care coverage—in any form—to a greater number of people, we have to start controlling costs across the board.

Stay healthy, Bruce.

Theresa Flaherty

by: Theresa Flaherty - Wednesday, November 25, 2009

So, I am reading some health care reform news today on Crain's New York Business.com and there is an article about how disease state management programs can reign in costs for diabetes patients. I don't belong to such a program, but I agree with the concept.

Apparently, UnitedHealthcare tested just such a plan this year with three national employers. What shocked me was that United says the average health care costs for an employee with diabetes (keep in mind, if they are employed, they aren't the blind, legless, dialysis patients) are $22,000 a year.

$22,000?! How is that possible? That's almost $500 a week. Does that seem high to anyone else?

I logged on my insurer's Web site to review my diabetes-related claims thus far for 2009. My total costs (both out-of-pocket and paid by the insurer) are roughly $4,586.71. That includes prescriptions (almost half), assorted bloodwork (standard for diabetes patients), one visit to the endo and two visits to the dietician.

Where on earth did the other $16,413,29 cents go? Am I just better than average at controlling costs? (Despite having insurance, I am always mindful of how much my insulin and test strips are if I paid retail). Do other people with insurance just say yes to everything cause someone else is paying for it? Do their doctors feel more free to order tests, etc? Are the costs just out of control?

Of course, I see the doc a little less frequently then others, stretch out my scripts longer than recommended, have skipped the eye exam so far this year and haven't gotten my $25 flu shot (Sorry Dr. B. they aren't available in Maine this season).

But I take care of myself, as recommended and try not to waste health care dollars—mine or the insurers. Isn't that what health care reform should be about?

Theresa Flaherty, Type 1, 10 years, 3 months

by: Theresa Flaherty - Monday, November 23, 2009

Dr. Earl Sunderhaus told an overweight patient she was fat. His medical license is now up for review.

Sunderhaus is an eye doctor. The patient complained that he poked her thigh and told her she is fat. Yes, this seems a bit, shall we say, inappropriate. He also scolded her as irresponsible for being unemployed and relying on taxpayers to pay for another pregnancy. Also inappropriate.

But, let's back up a minute, here. The patient is overweight, with diabetes and is pregnant. Is she insured? Uninsured? On Medicaid? If she is on government assistance, do taxpayers have the right to expect her to take personal responsibility for her health? And for the health of her child(ren)?

I suppose the point of this incident is that the doctor didn't behave professionally and that's where we should be concerned (concerned, but hardly outraged). But with trillion dollar health care reform looming, with a possible public health option included (for which I have no opinion yet), questions like this are going to continue to arise. Where do we draw the line between Big Brother and wasting money?

Theresa Flaherty

by: Theresa Flaherty - Thursday, November 19, 2009

Few people know about senseless government waste more than HME providers. But it seems beneficiaries might be taking notice as well.

A recent opinion piece on the sunnews.com asks "What is wrong with Medicare"? Written by a man name Joe, who turned 65 this year, it outlines his introduction to Medicare rules and regs regarding CPAP machines and supplies. Joe was diagnosed with a sleep study in 2006 and has been using CPAP ever since.

My sleep study was conducted at a sleep lab chosen by my insurance company, and the exam determined that I indeed suffered from sleep apnea after only 109 minutes of testing. However, despite being officially diagnosed with sleep apnea, Medicare rules require a sleep study lasting at least 120 minutes. Therefore, since I was 11 minutes short of their requirement, I must undergo another sleep study exam in order to qualify for the CPAP supplies that I have been receiving regularly for the past three years. The exam costs over $1,000, but I was told that I would not be billed for the sleep study because Medicare will incur all charges.

So, while Joe, the new Medicare beneficiary, has successfully gotten himself diagnosed and treated for three years, your government would like to shell out another $1,000 for him to retake the sleep study to recoup that extra 11 minutes. Meanwhile, we hear daily about soaring health care costs, soaring Medicare costs and millions of uninsured Americans. Undeterred, Joe attempted to reason with Medicare.

I called Medicare directly to advise them of this absurdity and spoke to two different customer service representatives in the hopes of convincing them that this was a unique situation that warranted an exception to the rule. However, I was told was that I needed to retake the sleep study or they would deny any CPAP supply claims.

The problem, of course, is that a bureaucracy offers no flexibility. It isn't, shall we say, nimble. Which should scare the beejesus out of everyone as all these unwieldy trillion dollar health care reform plans (although I haven't seen too much actual reform included) wend their way through Congress.

Why are Medicare costs so out of control? I think the problem starts with Medicare itself.

Theresa Flaherty

by: Theresa Flaherty - Tuesday, November 17, 2009

It isn't enough that a lot of Americans are overweight. Now, our pets are, too, apparently, a hefty 50% of them (disclaimer, I live with a rather large black cat, Bruce, but he came that way and is on a diet).

But, I digress. As I may have mentioned, November is National Diabetes Awareness month. It came to my attention this morning that it is also National Pet Diabetes Awareness Month.

Note: Not all overweight people develop type 2 diabetes, not all people with diabetes are overweight and I believe the same applies to pets.

Still, with 24 million people in this country with the disease, can I just say it is ridiculous that we now have to devote time and attention to the same common sense care and feeding of animals we should be taking with ourselves, and our (well, your) children?

Theresa Flaherty

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by: Theresa Flaherty - Friday, November 13, 2009

Tomorrow is World Diabetes Day.  Have you ever heard of it? It started in 1991 as a way to,  you guessed it, raise awareness about diabetes. The date, Nov. 14, was chosen because it is the birth date of Sir Frederick Banting, who discovered insulin, which I personally think is one of the greatest discoveries of the 20th century.

The International Diabetes Federation, which created World Diabetes Day, issued a Blue Monument Challenge this year. More than 800 monuments will light up in blue. The monuments include: The Empire State Building, Niagara Falls, the London Eye in the United Kingdom, the Sydney Opera House in Australia, Place de la Concorde in France and Tokyo Tower in Japan, as well as monuments in South Africa, the United Arab Emirates and Germany.

According to the IDF, there are 285 million people with diabetes world wide.

Theresa Flaherty

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