on mandates, and mandates

Let me begin with a rant.

Look, I know headline writers and Twitterers have to shorten stuff up.

But let's keep in mind that reforming "health insurance" is not the same thing as reforming "health care." Because insurance for care is not the care itself.

Is the cost of care relevant to the care that people get? Of course! Do insurance companies effectively practice medicine when they deny coverage for expensive treatment? You betcha!

But relying on changes to only one component of a very complex system to produce systemic *and positive* change strikes me as ... overoptimistic.

Words are all we have to articulate our goals. Let's be clear about what our goals are.

Now that I have that out of my system, let's talk for a moment about mandates.

No, not that mandate. I want to talk about the mandate that, if you own a motor vehicle in the United States, you, generally speaking, have to have a verifiable way of making good on the damage that your car does to other people and property. The way vehicle owners do this varies from state to state. In most states, it's through automobile insurance. In Virginia, if you "go bare," you have to pay the state an annual $500 fee. Mississippi lets you post a bond (which is just another form of insurance if you squint at it) rather than purchasing conventional auto insurance. New Hampshire only requires you to carry auto insurance if the state concludes you're at high risk of damaging somebody.

The general principle is this: you are required to carry auto insurance (or its equivalent) to protect other people from your screw ups. And it's prudent, frankly to have auto insurance to protect yourself from your own. As far as I can tell, the idea that you have to carry auto insurance to protect other people, that is, the general public, is not particularly controversial.

What is a requirement to carry insurance? It is a mandate.

Fast forward to the much more controversial mandate to purchase health insurance, or pay a penalty to the feds--much like the Virginia uninsured vehicle requirement above.

The most commonly-heard argument for the mandate has to do the economic necessity of getting young healthy people buying insurance they probably won't use to pay for the cost of old sick people using the heck out of their insurance. That isn't what I want to discuss in this post.

There is an entirely different risk-sharing/policy setting issue. Maybe it is discussed a lot and I've been missing those discussions.

Let's consider a young person. Our hypothetical young person ("HYP") is healthy, living independently, but of modest means. HYP therefore does not purchase health insurance, because it seems to be an unnecessary expense in a tight budget. HYP is gambling. Oh, sweet bird of youth!

On a dark and stormy night, HYP, crossing the street in a clearly marked crosswalk, is hit by a speeding car which vanishes into the night (because this is a hit-and-run, we can't file a claim against the motorist's theoretically mandated automobile policy--if he or she even has one). HYP is rushed to the emergency room and proves upon examination to have a shattered pelvis, a ruptured spleen, a lacerated liver, and a possible concussion, and is also noted to have a blood glucose level of 330, suggesting hitherto-undetected type 2 diabetes. Okay, the last is piling on a little bit.

Now. As a policy matter, we decided as a society in 1986 that the public should have access to emergency services regardless of ability to pay, by means of a federal statute known as the Emergency Medical Treatment and Labor Act ("EMTALA"). So the ER doesn't demand insurance information or cash up front from HYP, which is good, because HYP is unconscious and losing blood rapidly. The hospital just treats HYP. Because really, what is the alternative? Should we as a society say that it's OK to let HYP die? Or do we as a society assume the cost of HYP's care, one way or another?

Because HYP doesn't have health insurance, HYP can't get the negotiated in-network rate from the hospital. In a certain sense it doesn't matter, though, because HYP is of modest means, and couldn't pay even the in-network rate, let alone the hospital's pretend rate for the uninsured (which is another complex issue for another day--what are the hospital's actual losses from uncompensated care).

Patching HYP up even to the point where s/he can be discharged from the hospital is going to take some time. Meanwhile the bills are racking up, up, up. HYP might qualify for "charity care," depending on state law, or HYP can discharge the bills for the uncompensated care in bankruptcy. In either case, we as a society bear the cost when HYP gambles and loses. I personally would rather we bear this cost, as a policy matter, than let HYP die, or create a culture where we encourage our HYPs to just die already to save us all money. Having said that, I would still like to see a better method of risk distribution than we have now.

In the public debate, I see an occasional (well, okay, frequent) strain of blaming the sick for being sick, which I think is quite unfair, for no other reason than that accidents happen (speaking as someone who incurred a catastrophic injury in the blink of an eye last year). And people fall victim to bad genetics all the time.

In the realm of automobiles, Americans as a society have come to accept that accidents happen, that you're not "bad" just because you cause financial losses with your car, you just have to be a responsible adult and make arrangements for the unexpected. We agree as a society (other than New Hampshire, where you live free or die) that the "arrangements" should be auto insurance.

In the realm of bodies, it would make sense for Americans as a society to accept that accidents happen, that you're not "bad" just because you cause financial losses with your body (by having unexpected medical expenses), you just have to be a responsible adult and make arrangements for the unexpected. We clearly do not agree as a society that the answer is health insurance, even though having health insurance can protect other people from catastrophic losses.

I am not sure why.

Perhaps it is because insurance is such a boring subject.


the solution never works if you haven't identified the problem

I have a bias, I admit it. I am sensitive to studies with a subtext of "those stupid patients, what are we going to do about them?" Read the following rant with that in mind.

A pharmacy benefits manager a/k/a PBM funds a study of patients nonadherent to chronic prescription medication. The premise of the study, Effect of Reminder Devices on Medication Adherence: The REMIND Randomized Clinical Trial (hiding behind a paywall, by the way), is that "forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices." Thus, the intervention consisted of sending a population which included folks taking meds for schizophrenia and bipolar disorder either "a pill bottle strip with toggles, digital timer cap or standard pillbox" along with their mail order meds. There was of course a control group who received neither notification or a device. Surprise, surprise! Getting a prize in your Crackerjack box from your PBM does not improve medication adherence. Those stupid patients! Why won't they do what's good for them?

Well, let's take the most basic first step and look at the evidence that the REMIND paper cited in its very first footnote to support its premise that patient "forgetfulness" is the problem. The paper cited is not, thank you very much, behind a paywall. Its very title should have been a tipoff: "Unintentional non-adherence to chronic prescription medications: How unintentional is it really?" This study concluded that "For our study sample, unintentional non-adherence does not appear to be random and is predicted by medication beliefs, chronic disease, and sociodemographics. The data suggests that the importance of unintentional non-adherence may lie in its potential prognostic significance for future intentional non-adherence. Health care providers may consider routinely inquiring about unintentional non-adherence in order to proactively address patients' suboptimal medication beliefs before they choose to discontinue therapy all together [sic]" (emphasis added]

Reading further in the paper I've just linked to (which I highly recommend you do), "medication beliefs" include such things as "perceived need for medication"--statins, anyone?--and perceived medication affordability.

Let's go a little further and consider something obvious about clinician-patient dynamics in an era of managed care. How many clinicians take the time, or have the time, to initiate a thoughtful discussion with a patient regarding the benefits and risks of a course of long-term medication being recommended? A statin, say, or low-dose aspirin for primary prevention, in someone who feels just fine? How many patients will push through the clinician's subtle (or not-so-subtle) signals that s/he is pressed for time to initiate and then persist in a discussion, which might persuade a patient on the fence about the recommendation that there is an actual need for the medication? Or might even lead the patient and provider to jointly conclude that this long-term medication is not, after all, warranted?

Consider this: the more important you believe something to be, the easier it will be to remember to do it. "I forgot" is a convenient excuse we offer, after all, to our doctors. It is more polite, and less time-consuming, than initiating an uncomfortable conversation by saying, "I don't see the point of this/I am experiencing unpleasant side effects/I cannot afford this/I am overwhelmed by the 'treatment burden.' " Such comments can be taken as a direct challenge to the provider's authority, although they might stem from the provider's failure to communicate with/empathize with/educate the patient adequately in the first place.

A patient on insulin therapy is unlikely to forget to use insulin. It's obvious that insulin is important. This suggests another possible flaw in the study design. It excluded patients taking more than three medications, apparently because their dosing regimes are just too complicated (math class is tough!). It would be interesting to learn if patients taking more medications might actually be more adherent because they feel that the stakes are higher. Alas! We will never know, at least from the authors of this study hellbent on reminding these silly patients who just cannot remember what is good for them. Although the study design notably did not include smartphone apps such as Mango Health that "gamify" taking medications and could use more investigation.

I feel compelled to point out as well that patients getting their meds mailed from their PBMs are by definition not in regular contact with an overlooked, underrated member of the patient's care team: a flesh-and-blood pharmacist who reinforces dosing instructions, and provides that human touch. Yes, it is possible for a patient to make contact with an actual pharmacist at a PBM, but I wonder how many nonadherent patients are aware of that.

I should finally note that many patients view PBMs as an arm of their insurance company (which in fact they are) and may have viewed what appeared to be medical advice coming from their insurer as inexplicable and suspect. Indeed, "[b]ecause the study devices are currently available for commercial use and because participants received the devices by mail and could choose not to use them, patient-level consent was waived by Chesapeake Institutional Review Board." Not obtaining consent may have made the study less useful, but I'm sure it was cheaper, amirite?

The writeup of the REMIND study grudgingly concedes towards the end that "because nonadherence is a multidimensional problem, addressing forgetfulness alone may have been insufficient to improve actual medication taking." This spectacularly misses the boat. Because it's not truly a problem of forgetfulness at all.


when a provider gets it right

I sent a thank you note today (from time to time, I like to use my powers for good).

Dear Doctor X [Chief of Anesthesia at Big Hospital]: I wanted to take this opportunity to commend your entire team for its thorough engagement with me after my inquiry about glucose control protocols while I prepared for my most recent surgery at Big Hospital at the end of last month.

Doctor Y herself [Head of Preoperative Clinic] took the time to review my preoperative instructions with me the week before surgery, including explaining the rationale behind stopping supplements, etc.  On the morning of my procedure, which was mercifully scheduled as first case, Ms. Nurse Manager made it a point to introduce herself upon my admission to the pre surgery unit and to explain the improvements that Big Hospital is making, giving me the chance to calibrate my home meter against the first reading taken. I noted also an intraoperative and a postoperative blood glucose reading in eCare. I would like to commend your team for their thoroughness in my treatment, which I know encompassed much, much more than blood glucose monitoring, and their detailed record-keeping.

As a person with diabetes, I am accustomed to managing my own condition for the 99% of the time that I am not in contact with the medical system. I take this responsibility seriously, and so I am prone to remain somewhat vigilant even amidst the medical system absent a very clear handoff. It was a relief to be able to turn over the reins, so to speak, of my diabetic care with confidence for the time when I was unconscious.

Finally, I remain impressed that the "Patient Feedback" button on your department's website goes straight to the top. It speaks well of you and your team that you seek to interact with patients without hiding behind rank. I can only say that my anesthesia experience has proven very positive and I thank you all sincerely for your efforts, your time, and your knowledge and skill.


more fun with PBM appeals

The PBM denied the first appeal (more on that later).

The form called "Important Information about Your Appeal Rights" provides a number to call "for information on how to designate an authorized representative."

I try looking on the PBM website first and cannot find an authorized representative form.

I call that number to get the form. Person #1 gives me a URL that leads to a 404 notice (big surprise).
She transfers me to Person #2 at a new phone number.

I ask person #2 for the information on how to designate an authorized representative to file an appeal.
She has no idea talks to her supervisor.

She comes back and tells me that her supervisor says I have to fill out the form and send it in.
I explain that I am calling because I need the form.

"Oh," she says, "my supervisor says you have to get it from the website."

I explain that neither person #1 nor I could find it on the website.

"Oh," she says, "I have to transfer you to person #3 at yet another phone number!"

At which point I am disconnected.

I am in Hell.


i don't know how other people do this

I submitted a claim last month on behalf of a family member for a compound prescription medication (eye drops with a higher percentage of active ingredient than readily available).

The claim was denied by our PBM because, according to them, it "contains non-covered ingredient(s). Your prescription drug plan does not cover this medication."

The denial did not identify which of the "ingredient(s)" were allegedly not covered.

The compound prescription had four (4) listed ingredients, including sodium chloride (at a cost of seven cents).

Here is what I had to do in order to appeal the claim.

(1) I looked at the original form from the compounding pharmacist and developed a hypothesis that there was only one active ingredient.
(2) I went to the website of our PBM and searched their current formulary. I found the same delivery system of the same active ingredient (at a different concentration) listed, and printed out the page proving that the active ingredient was covered.
(3) I went to DailyMeds and printed out the drug information, including the ingredients list, confirming my hypothesis about which of the four ingredients was the active one and also proving that the three inactive ingredients in the compounded prescription were also used as a buffer in the formulary drug.
(4) I filled out the appeal packet, explaining all this and attaching the denial letter, the claim showing the list of ingredients, the page from the formulary showing that the medication was generally covered and the drug information showing that the inactive ingredients were the same.
(5) I mailed the appeal certified mail, return receipt requested, because I don't trust these people to keep track of anything anymore.

The worst part of all this is that the compounding pharmacy charged us less than the listed price of the formulary drug. So going this route should save the PBM money.

Of course, just denying the claim outright was even cheaper.

At first.

But I have to wonder. What do people do without good research and verbal skills and some knowledge of chemistry?


the further adventures of radiology department a

Part One here.

I was looking at my EHR with Radiology Department A two days ago, as one does, and I noticed that, despite my best efforts, an actual doctor there--let's call him Doctor X--took the time to reread my film a couple of days ago, and repeated his recommendation for followup testing. Sadly, this waste of his time took place a full week after I sent an agonizingly detailed letter documenting the results of the actual followup testing (including the radiologist's report from Radiology Department B).

I faxed Radiology Department A another copy of the agonizingly detailed letter, with a cover sheet to the attention of Doctor X, apologizing to him for the waste of time, thanking him for his conscientiousness in followup, and reassuring him that I had not only followed his recommendation but provided Radiology Department A with a copy of the report a week before he reread my film.

I called Radiology Department A and reviewed my fax with an office manager, whose name and direct line I now have. She said she would kill any ticklers in the EHR to end any further followup.

I suppose I shouldn't have done this, but I went back to my EHR for Radiology Department A last night, just to double-check.

And there I found a Visit Summary for the followup appointment that I cancelled twice on the phone, and once in writing. This may be the fault of Epic. It really makes me want to pin somebody's ears back.

I now await a bill/stern letter from Radiology Department A for my "missed" appointment. If this happens, I will start naming names.


possibly the most boring post i will ever write

Apparently, my health insurer Aetna, which is actually not an "insurer" at all but a TPA, is changing PBMs from Express Scripts to CVS Caremark.

To decode that last sentence and its significance:

A "TPA" is a third-party administrator of the health benefits that are being provided by a large company which is actually "self-insured."  When you are dealing with health benefits you need to understand who is actually providing them because you need to understand the rules that govern them and the pressure points if you need to complain when things go awry. For example, generally speaking, a self-insured plan isn't going to fall under the jurisdiction of the Commissioner of Insurance for your state, so cc'ing them on a Stiff Note is really not much of an implied threat. Self-insured plans fall under the loving care of the feds, in particular the Department of Labor and the Internal Revenue Service, but they tend not to be that consumer-oriented. Also, they're really busy.

A PBM is a "pharmacy benefits manager." This is a subset of TPAs in charge of arranging for payment (or not) of medications and (some types of sort-of DME, see digression below) prescribed by the clinicians who are paid for by the benefits administered by another TPA. Because that is more efficient (it actually may be, for all I know. Pardon my momentary cynicism).

The PBM switch has apparently been in the works for a while, and I am pretty sure that the transition was contemplated to occur in 2017 (like, January 2017).

The hotlink on Aetna's website to the press release announcing its "strategic alliance" is, of course, broken (when I pointed this out to the Health Advocate she actually snorted).

The "Q and A for Aetna Members" says "we will keep your employer informed."

The employer (of the consort of the Dark Goddess) knows nothing of when or how the PBM transition will be implemented. For all I know the deal fell through or was blocked by the Justice Department on antitrust grounds.

Our family is strong-armed into ordering a great deal of our medication (and certain types of sort-of DME, see digression below) through a PBM or face stiff financial penalties for the "luxury" of using a retail pharmacy. I have no information about how our scripts currently residing at Express Scripts currently eligible for refill will or will not be transferred to CVS Caremark, and when. Maybe it will be seamless. I should note that historically there has been considerable lag time between the time when we mail our prescriptions from Washington state to the processing center, which always seems to be in Florida, and the time the prescriptions are shipped from some other far-flung part of the country. When I can coax a clinician into e-prescribing, that reduces the transit time of one leg, but only one leg, of the journey.

My promised digression: one of the great oddities of my current PBM is that, if you get a "prescription" for medication that is available over-the-counter (for example, low-dose aspirin), the PBM will provide it essentially free (because this sort of preventive medication is regarded as a good investment in your health). Also, there are certain types of "durable medical equipment," or DME, also available over-the-counter, but that if "prescribed" are also provided more cheaply than if just purchased at the store. The oddity goes up to eleven when you realize that DME includes items that are not durable at all because they get used up, for example, lancets and glucose monitor test strips. And the rules on what DME you are "allowed" to buy from a pharmacy in order to have coverage are Byzantine. This summer I found out that my pharmacy was not a DME provider for crutches, but it was a DME provider for lancets and test strips, which was a distinction that was never satisfactorily explained to me.

Aside from the possible gap in fills, here are significant differences between the 2017 formularies of the two PBMs (the new one, of course, seems more restrictive than the old), so which PBM will be in place for the future is actually important for me to track down.

I have asked both Aetna and Health Advocates for information and we'll see who can clarify it first.


i made a difference today

I found out this morning that my paralegal wasn't intending to vote today because she didn't think she was eligible for a replacement ballot. Based on her quick check of the King County website, she thought her voter registration was no longer valid (she is an intelligent person, just intimidated by the process). I asked her cautiously--I am her boss, after all--if she wanted me to talk her through the process of getting a replacement ballot, which she did.

We went to the King County Elections website together, and were able to confirm that she was still a validly registered voter and eligible to vote. With her consent, I printed out a replacement ballot for her. Then I handed it to her and told her to go vote for whomever the hell she wanted, but to please go drop her ballot in the ballot box across the street from the courthouse (two blocks from our office). And gave her time off to do it.

Someone voted today, because of me, who would not otherwise have had a voice. I feel good about that, and I really don't care who she voted for.


hello, my name is...

I competed for several years in extemporaneous speaking in high school.

I took classes in college where the exams were 100% oral. And in Russian.

I have been going to court since 1984. I make my living with my voice.

I rarely use a word-for-word script any more. Sometimes, to show off, I have given major talks/arguments without any notes at all. Invariably, however, I prepare notes in advance, and they always start out the same way: Introduce self. 

Then I put my name in parentheses in my notes.

Why? Because stress makes us stupid.

Although it hasn't happened yet, it is still entirely possible that I might someday forget my own name at the beginning of a presentation.


the other side of defensive medicine

I wrote a stupid and annoying letter today.

The letter itself was very polite. But I wrote it because I was afraid, and that is what is stupid and annoying.

What was I afraid of? Being branded a "noncompliant" patient.

Why am I afraid of this? It's like a stink you can never get off.

What did I do that created this fear? I cancelled a followup x-ray at Radiology Department A because I don't have a doctor at Hospital A any more. All the rest of my local care is at Hospital B right now, so I wanted the follow-up to be done at Radiology Department B where all my other doctors are.

(Parenthetically, the reason that I don't have a doctor at Hospital A any more is that my doctor there quit Western medicine to become an energy healer, but that is another tale for another day.)

I thought I was really on top of things when I called Radiology Department B to get them to request all my films, scheduled the new appointment when the films arrived, and then and only then called Radiology Department A to cancel, explaining that the follow up was being done at Radiology Department B because they still had doctors practicing evidence-based medicine there and I had no clinician at Radiology Department A.

And then.

The next day I got an anxious call from Radiology Department A. We need to you be seen.

Well, I called and cancelled yesterday because I have the same appointment somewhere else. You just sent the records.

Oh. We don't have a record of that. It's very important that you be seen.

I explain again about my old doctor leaving Western medicine and my consolidating all my care to Hospital B.

This morning I checked on the EHR portal of Hospital A. Sure enough, they're still flagging me for overdue follow ups.

That's when I accepted: I'm in the Hotel California. Hospital A and Hospital B are, although nominally nonprofits, competitors rather than cooperators. There is no real system to track the transfer of care. Moreover, weeding out all flags from a big database is really, really hard. From their perspective, I represent a potential liability because they spotted a potential problem and recommended that I follow up. I get that. Unless I prove that the loop is closed they can deem me "noncompliant" and get rid of their exposure that way.

So I sucked it up. I wrote Radiology Department A a letter today, thanking them for all the lovely care (and they really have been nice over the years), reminding them that I have transferred care, and why, and enclosing a copy of the results of the follow-up x-ray from Radiology Department B.

Now that ought to do it.

Update: well, that was naive.


dear sergeant

I would like to express my appreciation to you and your marshal for meeting with me on Tuesday afternoon, October 18, 2016. We met to discuss the incident earlier that day in which my personal mobility aid was confiscated before my entry to the Maleng Regional Justice Center, and I was required to use a completely unsatisfactory, presumptively unsanitary, and stigmatizing substitute mobility aid in order to obtain access to the courthouse.

Although I appreciated the promptness with which we were able to conduct at least an initial discussion of the incident (indeed, the very promptness and informality with which the meeting was set up may have been a contributing factor), the meeting itself raises an additional concern for me.

I offer the following thoughts for consideration of future meetings of this sort:

You and your marshal, two very tall and imposing men in full sheriff's regalia, directed me, an officer of the court, to a secluded conference room in the courthouse library, to receive my concerns. I laid my cane down—which had been confiscated from me by one of you just hours before as a dangerous weapon!—on the table between us, within my reach, as we spoke.

Many, if not most, people would find providing unsparing criticism face-to-face with two authority figures, particularly law enforcement, alone in a confined and secluded space, a highly intimidating prospect.

I am not asserting that there was any conscious intent to intimidate me. Your choice of venue for our discussion, however, which I was hardly in a position to challenge as an officer of the court bound to cooperate with law enforcement, reflects a lack of understanding of its effects. I would imagine that it is automatic for you to seek to control any situation that you enter, given your line of work, but there is such a thing as overcontrolling a situation. You may also have been wishing to provide confidentiality for a discussion that might be expected to touch on my disability. If so, I thank you for that, but there are better ways to address that concern.

It occurred to me after the fact, but only well after the fact, that, had one of you made a snap judgment, during this meeting, that I was making a “threatening” or “aggressive” move towards my cane, and that I therefore needed to be "subdued," I would have had no way of establishing that the facts were otherwise. Given: the initial suspicion with which my innocent cane was met (to the point where someone who actually had held it in his hand believed that the head was made of metal, rather than resin); the intensity of my feelings about the situation to which I had been subjected; and my tendency to wave my hands around when I talk, I wondered in retrospect if I placed myself at greater risk than I realized by acquiescing in your chosen venue for our meeting. I also wonder now if I should have insisted on a witness/advocate on my own behalf, which was not presented as an option for me, before going forward with our meeting. Indeed, if our recollections differ about what was said during this meeting, since it was not recorded, I have been placed at a (numeric) disadvantage.

You were both clearly taken aback by the intensity of my distress, or at least the force with which I articulated that distress. I am somewhat relieved, in retrospect, that my impassioned plea for treatment with dignity was not misevaluated as potential aggression.

Although I was not daunted at the time by the venue of our discussion, I am sending this followup letter because I suspect that my background and temperament make me unusual in this regard. The difficulty of protest when deprived of access to an accommodation, even for a person such as myself, means that such slights occur much more frequently than are ever brought to your attention. In fact, I did find my initial interaction at the courthouse entrance highly intimidating, and I had to compose myself before I could place my initial call to the ADA coordinator. An intimidating venue, however innocently selected, adds an additional barrier to such issues being brought effectively to your attention.

I hope that you can receive this additional feedback in the spirit in which it is intended. You did ask me in my meeting what suggestions I might have for the future, so I may I add to my suggestion that you develop a coherent policy for mobility aids a suggestion that you use less discouraging venues for the discussion of ADA complaints. I don’t know if there is a usual protocol for these meetings that was bypassed in my case.

As a family law attorney, I want safe courthouses just as much as you do. But as a family law attorney, I also want everyone without ill intent to have access to those safe courthouses. Arbitrary denial of access serves no one. Remember: every cane is a “stick."