When Prostate Cancer Returns – Ouch Mayo Clinic Fumbles the ball… Part 9

Some posts are simple and don’t require many words.

Mayo Clinic pre-certification department – 100% satisfaction rating.  Talking about a group that has gone above and beyond the call of duty…these folks certain have.  Hats off to you.

Mayo Clinic Urology dept… well it started at 100% and I can honestly say they are good – real good – but when it comes to patient first or process and time – patient loses if they pay with insurance.

Let me explain.  National Imaging Association denies the C-11 Pet Scan which would be the most likely test to determine the source of my recurrent prostate cancer.  What they require is a Peer-to-Peer consultation with the folks at the Mayo Clinic.

Why?  Likely because this particular Pet scan is so highly specialized that the NIA folks need to be “convinced” (my word) that its useful in my case.  To be fair, Dr. Kwon, through the Mayo pre-certification dept sent extensive material to help them understand.  Do I think the folks at NIA read it – na…not a chance.

But the problem is – Dr. Kwon and the Mayo Urology folks don’t (won’t) do peer-to-peer consultations with insurance companies.  I was told if they did that is all they would do and therefore get no scans done.

Wait a minute…time out.  You’re telling me that you (the Mayo Clinic) can’t hire someone with clinical urology experience to handle the interaction with insurance companies so that patients (like me) don’t get caught in the health insurance circle of death?

Sorry, but it is unacceptable that no one with enough specialized knowledge from Mayo Urology can take the time needed to do the peer-to-peer knowing that this test is “the” test needed to help me get appropriate direction needed for an effective treatment.

One call, but the Mayo Clinic won’t make that… at least that’s what I have been told for two days.  So much for the patient coming first.  Remember I (your patient) didn’t create this screwed up system of health care or payment system.  I just need cooperation so I can move forward to eliminate this disease once and for all.

You sure you won’t make the peer-to-peer call?  Please!

When Prostate Cancer Returns – The Great Health Insurance Run-around! – Part 8

I am becoming more firmly convinced that the health care system is so screwed up that recovery is challenging at best.  Wonder if we should call in palliative care for our health care system?

Many of you have been following my journey dealing with recurring Prostate Cancer.  Treatable?  Yes!  Easy?  No!!!

THE GREAT INSURANCE RUN-AROUND!

Yesterday was a red-letter day when it comes to getting the run-around from all sources.  Even the great Mayo Clinic contributed (but we’ll get to that later).  Since this is in two parts – the first part was posted yesterday and can be seen here:  https://chuckgallagher.wordpress.com/2013/11/26/health-insurance-companies-and-the-ethics-of-health-care-you-aint-gonna-believe-this/

In my case since I was denied the test that I need to identify the source of my recurrent prostate cancer, I elected to call Blue Cross – Blue Shield of SC.  Ooops…calling – well that’s not possible.  Rather you have to communicate through their BC/BS website (something I can do, but not sure it’s easy for all customers/patients).  The connection with BC/BS was to appeal their denial.

BC/BS says – Sorry, but National Imaging Association is who issued the pre-approval denial and they would have to be the ones to reconsider.  Fair enough…

So I call National Imaging Association and was told that I was denied because the Mayo Clinic in its submission for approval indicated “Prostate Cancer” but did not provide a “tissue diagnosis”?  Bureaucratic bulls**t.  What tissue is there to diagnose?  My PSA is rising and that has only one practical source – recurrent prostate cancer.

CHINK IN THE MAYO CLINIC ARMOUR

Following the logical process…I follow up with the Mayo Clinic pre-certification folks and am told that they have done all they can do and that a peer-to-peer might be in order.  Seems reasonable to me.  So I am told to talk to Dr. Kwon’s admin to seek his help.

Moments later I talk to Dr. Kwon’s admin and, well I must have called either on a bad day or too late in the day.

“Why are you calling me?”

“The folks at the Mayo pre-authorization or certification dept told me to call as a peer-to-peer might be in order,” was my response.  They just told me this minutes ago.

“They shouldn’t be doing this.  Dr. Kwon is not going to do a peer-to-peer with an insurance company.  Do you mind if I put you on hold while I resolve this with the pre-authorization dept.  They should have never had you call me.”

On hold…and I’m thinking “well that didn’t go well” – as the patient what message was sent that my doctor who is the champion of this particular procedure would not do a peer-to-peer.  I really do get it…that is time and time is money, but reality is if that is what is required surely there is a solution other than complaining about receiving a re-referral from another department within the Mayo organization.

THE GAME

I’m becoming more and more confident that the insurance company game is played this way:  DENY! – wait and see if the patient or doctor’s office gives up = INSURANCE COMPANY WINS!

Well, I don’t give up that easily either with the insurance company or the Mayo Clinic.

Looks like its back to the phones for me!

YOUR COMMENTS ARE WELCOME!

Health Insurance Companies and the Ethics of Health Care…You Ain’t Gonna Believe This!

Some may know – especially those who have been following my most recent blogs related to a return of Prostate Cancer that I’ve been dealing with – but today was a Red Letter day when it comes to Health Insurance, Health Insurance Companies and how they ethically (oops unethically) deal with their customers.  I am not sure how we got here, but where we are when it comes to our health and how that is paid for is so broken it’s quite unbelievable.

WHAT’S THE SCOOP?

Today was a follow up visit with my local doctor.  Nothing special and almost a waste of time, but the appointment was scheduled and kept.  Routine visit – weight, blood pressure, temperature, and nothing unusual.  Today I was to receive the results of my bone scan and CT scan, but since I got a CD with the data ready to send to the Mayo Clinic (which of course I read – not that I’m a doctor, but I can read, and a report that says nothing was found was exactly what I was expecting), which I sent, I knew the outcome before the visit.

Doctor enters the room with a pleasant smile asking me how I am.  Now that was a loaded question since I am full of frustration over the way Health Insurance companies deal with their customers (namely me).  Of course since I am the one that wants treatment, I personalize their actions.  Yes, I know better, but to me it is personal since it is my health.  So…I proceed to vent to the doctor.

“Doc, I don’t know how you deal with these insurance companies day in and day out!  They are a pain in the ass.”

“You don’t know the half of it,” he responded, “and it’s only getting worse!”

For a few minutes he openly allowed me to vent, then looked at me, removing his glasses and said, “Let me vent a bit.”

AMAZING STORY!

Of course with no identifying information shared, my doctor shared with me the most amazing story I’ve heard (and I suspect that this is nothing in comparison to many many more stories like this out there).

“So I have a patient with advanced lung cancer.  He’s been a smoker most of his life, so as you can imagine his lungs are pretty damaged.  Likewise, he has cancerous lymph nodes in his chest.  So I suggested a form of radiation treatment that is more localized to his tumor so that I can spare what little lung he has left.  If I use traditional radiation the tissue damage will create substantial problems for this man who needs to salvage as much of his lung as possible.

I submitted my request to his health insurance company.  Their reply:  DENIED.  They wanted me to use the conventional treatment!

I told the person on the phone, because by now I was personally involved, that if it were their lung or even their father in a similar situation, they would want the better treatment.  The treatment that would salvage what lung he has left.

They then suggested that I resubmit the request showing the two treatments: (1) more effective treatment and (2) conventional tissue destroying treatment.  We did that.

Got the response today:  DENIED!

I was incensed and called again for a peer to peer discussion.  Not more than 30 minutes ago I was told that the conventional treatment was all that was needed, even though I know that the damage from that will substantially diminish his quality of life and could create more medical costs down the road.

Chuck, they just don’t care!”

HOW DID WE GET HERE?

How did we get to the point that a person checking off a checklist is the determining factor into the kind of health care we receive in the United States of American?  Are we really OK with care provided at the lowest common denominator?  We we can receive quality treatment but the insurance company will only pay for adequate treatment, is that OK?

SHARE YOUR STORY

You don’t have to name names, but feel free to share your story.  Maybe if enough of us get our stories told…SOMEONE WILL LISTEN.

FEEL FREE TO SHARE YOUR STORY OR YOUR COMMENTS.

Does Scott Brown’s Win mean Health Care Reform should be Scrapped?

With a decisive win in MA, Scott Brown has taken a Senate seat that was held by Ted Kennedy for decades.  Kennedy, of course, is known as the primary supporter and author of the Health Care Reform bill that is currently before Congress.

Now, President Barack Obama and the Democrats, which held the the 60-vote Senate majority that they’ve relied on to push a historic health care overhaul to the verge of enactment, find that they may see Health Care Reform derailed before enactment.

According to MSNBC – Democrats splintered on how to salvage the president’s top domestic initiative even before the results were official. Republicans said don’t bother: The election of state senator Scott Brown sent a message that the health care bill should be scrapped.

Democrats don’t appear to have enough time to resolve differences between the House and Senate bills — and get cost and coverage estimates back from the Congressional Budget Office — before Brown is sworn in. That leaves House Democrats with the unpalatable option of passing a Senate bill that many of them profoundly disagree with.

“There is only one guarantee — that if we don’t pass something the notion of trying to put Humpty Dumpty together again is a real long shot,” said Rep. Patrick Kennedy, D-R.I., son of the late senator. “If you understand the legislative process, it’s a lot easier to pass something and fix it later.”

So as the days unfold several questions arise:

1. Should Health Care Reform be scrapped?
2. Should Health Care Reform be revisited and move forward more slowly, but with the intention of passing something?
3. Is Brown’s election a broader measure of Obama’s political support?

YOUR COMMENTS ARE WELCOME!

Kansas City Internal Medicine doctors turn away Medicare enrollees, sparking ethics debate

Here’s a question for you: If you had a service to provide — and someone asked you to provide it for free, or at a radically reduced price — would you do it?

No, right?

Now try this on for size: If you were a doctor, and someone asked you to provide a service at a rate that didn’t reimburse you for the total cost of care, would you do it?

In nearly every line of business, one maxim holds true: “If you can’t pay, we don’t play.” So, why should doctors be viewed any different?

That’s the question doctors at Kansas City Internal Medicine, the largest private group practice in Kansas City, Mo., have been asking. For now, most of these doctors, who count 65 percent of their 70,000 active patients age 65 or older, have decided to stop accepting walk-in Medicare enrollees.

Dr. David Wilt, an internist at the group, tells CNN: Medicare doesn’t reimburse physicians enough to cover the cost of care. Matters will only get worse, he adds, if a 21 percent cut in Medicare payments to physicians takes place in 2010.

Should physicians be allowed to turn away patients because their funding source is being reduced? On the flip side, does the government have the right in a free-market economy to dictate payment terms to physicians for the performance of services?

Share your comments here.

Senator Grassley: Another Inquiry – What Did Pfizer Pay to Faculty Members at Harvard Medical School?

The last time I wrote about Senator Grassley was when he requested financial data from six tele-evanglists.  Looks like that went basically no where.  Too much resistance perhaps.  Now the Senator has requested information from Pfizer.    In a New York Times article it is reported that Senator Grassley asked the drug maker Pfizer to provide details of its payments to at least 149 faculty members at Harvard Medical School.

Senator Grassley’s letter is reproduced as follows:

Jeffrey B. Kindler
Chairman of the Board and Chief Executive Officer
Pfizer Inc.
235 East 42nd Street
New York, NY 10017

Dear Mr. Kindler:

The United States Senate Committee on Finance (Committee) has jurisdiction
over the Medicare and Medicaid programs.  As a senior member of the United States
Senate and as Ranking Member of the Committee, I have a special responsibility to the
more than 80 million Americans who receive health care coverage under those programs
to ensure that beneficiaries receive drugs that are both safe and effective.

For the last three years, the Committee has investigated various aspects of the
pharmaceutical industry including industry funding for Continuing Medical Education
(CME), and the failure of physicians to disclose payments from industry when applying
for grants from the National Institutes of Health (NIH).  Further, inquiries have led the
Committee to believe that physicians are failing to disclose the money they receive from
companies as required by federal regulations governing NIH grantees.

I am currently looking further into these concerns.  I was greatly disturbed to read
an article in The New York Times documenting an employee of your organization who
was taking cellphone photos of Harvard University (Harvard) medical students
demonstrating against pharmaceutical influence on campus.  I find this troubling as I
have documented several instances where pharmaceutical companies have attempted to
intimidate academic critics of drugs.  Last February, I sent a letter to the Secretary of
Health and Human Services pointing out that a pharmaceutical company hired a private
investigative firm to background an FDA public safety officer.

While I am not certain that photographing demonstrators rises to the same level, it
does raise concerns that Pfizer is attempting to intimidate young scholars from professing
their independent views on issues that they think are critical to science, medicine, and the
health and welfare of American taxpayers.

Accordingly, I request that you provide the following information:

1) A detailed account of payments and/or benefits of any kind that your company
has given to the 149 Harvard faculty members mentioned in The New York Times
article, and any other unreported Harvard doctors receiving payments.  The time
span of this request covers January 1, 2007 through the date of this letter.  For
each doctor receiving payments, please provide the following information for
each payment:

a. Name and title of doctor,
b. Date of payment,
c. Payment description (CME, honorarium, research support, etc),
d. Amount of payment, and
e. Year end or year-to-date payment.

2) Any communications to include emails, faxes, letters, and photos regarding
Harvard medical students demonstrating and/or agitating against pharmaceutical
influence in medicine.  The time span of this request covers January 1, 2008 to the
present.

In cooperating with the Committee’s review, no documents, records, data, or
other information related to these matters, either directly or indirectly, shall be destroyed,
modified, removed, or otherwise made inaccessible to the Committee.

I look forward to hearing from you by no later than March 10, 2009.  All
documents responsive to this request should be sent electronically, on a disc, in
searchable PDF format to Brian_Downey@finance-rep.senate.gov.  If you have any
questions, please do not hesitate to contact Paul Thacker or Emilia DiSanto at (202) 224-
4515.

In an article entitled: Harvard Medical School in Ethics Quandary the following was reported:

In a first-year pharmacology class at Harvard Medical School, Matt Zerden grew wary as the professor promoted the benefits of cholesterol drugs and seemed to belittle a student who asked about side effects.

Mr. Zerden later discovered something by searching online that he began sharing with his classmates. The professor was not only a full-time member of the Harvard Medical faculty, but a paid consultant to 10 drug companies, including five makers of cholesterol treatments.

“I felt really violated,” Mr. Zerden, now a fourth-year student, recently recalled. “Here we have 160 open minds trying to learn the basics in a protected space, and the information he was giving wasn’t as pure as I think it should be.”

Mr. Zerden’s minor stir four years ago has lately grown into a full-blown movement by more than 200 Harvard Medical School students and sympathetic faculty, intent on exposing and curtailing the industry influence in their classrooms and laboratories, as well as in Harvard’s 17 affiliated teaching hospitals and institutes.

As an ethics speaker, often I hear complaints about banking and finance, yet ethics extend into all areas of enterprise.  Pfizer has agreed, unlike the tele-evanglists, to cooperate fully with Grassley’s requests.  My guess is that Pfizer will be exposed for what likely has been an industry standard – shall we call it “payola”?  Harvard, without admitting guilt, of course, will find a source of funds drying up and be embarrassed by their choices or “ethics” being called into question.

What do you think?  Is it unethical for an individual or organization to take money from vendors when it has been an unspoken industry standard?

YOUR COMMENTS ARE WELCOME!

Abdul S. Rao Associate Vice President at the University of South Florida Resigns – Choices and Consequences

Every choice has a consequence.  For whatever reason, a Vice-President who helped steal a student bicycle resigned.  His choice cost him his job.

Here’s the story from The Chronicle of High Education:

Just days after someone posted security-camera footage to YouTube that showed an associate vice president at the University of South Florida helping someone steal a bicycle, the administrator, Abdul S. Rao, is resigning.

Stephen K. Klasko, dean of the university’s medical school, announced at a faculty meeting last night that Dr. Rao would step down effective this Friday. Dr. Rao, senior associate vice president for research in the university’s health division, admitted that he had helped a day laborer take a bicycle parked at a loading dock behind the university’s Byrd Institute.

He said in a statement that a “lapse of judgment” led him to give permission to a “nearly homeless man” to use the bike, which a student later reported stolen. “I have no excuse,” Dr. Rao said in the statement. “I can only say that my intention was never to bring harm, alarm, or disruption to anyone.”

The student whose bike was stolen asked the police for the security-camera footage, which the student then placed on a server that others could see, according to press accounts. Someone then posted the footage to YouTube, where it received thousands of views before it was removed because of an unspecified violation of the video-sharing site’s terms of service. Michael J. Hoad, a vice president for communications at the university, said in an interview that the leaking of the video was “a minor secondary issue” that the university had no plans to investigate.

What was Dr. Rao thinking?  Did he have such compassion for a homeless person that he lost his sense of ethics?  Often in an electronic age the assumption is out of sight out of mind.  However, not much today is out of sight – especially with internet services like YouTube.

From an ethical perspective – do you feel that Dr. Rao should have resigned?  Will the good work that Dr. Rao be lost due to a lapse of his ethical choices.

Diagnosed with Prostate Cancer? Help with Research for a New Book!

Let me be clear from the beginning – I am not a physician, not a part of the medical community, nor associated with any organization that profits from cancer or it’s treatment.  Rather, I am a man who is a prostate cancer survivor.  I have been through what, if you are reading this, you are going through or someone you love is going through and I know the ropes.  That does not mean I have the answers to all your questions, but more than likely I have asked them.

I have dealt with the emotions associated with the initial diagnosis.  I have researched and researched treatment options and feel, that from a layman’s perspective, I have a good grasp on the benefits and detriments of most common treatment approaches.  Most importantly, I know what the side effects are and have, within reason, been able to overcome them.

Search this site, if you have not already done so, and read the entries as they have become well read by men and women alike.  Then if you have questions, feel free to e-mail me.  I will respond.  I am blessed to be cancer free and feel that if I can share what I have come to understand with others I will, in my own way, pay it forward.

Likewise, I am writing a book about my experience and the experience of others in this arena.  If you would like to become a part of this work, please e-mail me at chuck@chuckgallagher.com – we will then set up a time for an interview.  Believe me your input will help.  You and the experience you have had can make a difference.

My best to you and don’t hesitate to make contact.