I recall one man who put a sign on his lawn and in his office that he was “Dr.” when, in fact, he had a master’s degree. This fraud was included on his letterhead, where he put a number that appeared to any unaware person to be a licensed number. It was not his license at all but a number for some other activity in which he engaged.

The licensing board had repeatedly warned him to rectify the situation, but he didn’t because he knew that there wasn’t enough staff to go out and check on his actions. Everyone thought he was a medical doctor or a psychiatrist in the town where he practiced.

Another large practice had secretaries administering psychological test materials for which they neither had experience nor degrees. Ethically, they should not have had access to these materials.

Everyone who came to the practice was put through a series of computerized tests, and their insurance was charged for all of this unnecessary testing. The practice reaped millions of dollars a year, and nothing was ever done to the man who owned it. He even charged insurance for missed therapy sessions, which is outright insurance fraud.

The secretary administered a basic IQ test at another office, not a therapy office, but offering a different service. The testing material was kept on her desk. Nothing was ever done about this, either because the man in charge was not a licensed healthcare professional, and he was never investigated for this practice.

Anyone wishing to check on a licensed mental health counselor can go to the state–by–state listing on the Internet. For licensed psychologists there is also a similar listing. Psychiatrists are listed as medical doctors.

Then, there are those who call themselves doctors who may have degrees in things other than healthcare-related specialties, such as administration or even history. The term is not carefully regulated and may be used by so many people that it is, and can be, intended to deceive.

There are also those who catfish on the Internet and present themselves as something other than who they truly are. I am speaking about authors who delve into the intimate, personal lives of young people and then use this material to write books. Is it ethical? Do these people really respond to anything regarding ethics? I find it absolutely untenable.

What about those who “graduated” from schools that have been shut down because they were nothing but diploma mills? Yes, they are out there, and when they write their website profiles, they carefully exclude any mention of the school and say they have “studied” topics such as neurobiology or science.

Taking one course could be seen as “studying.” Are they expert in any area? Deceit and deception are their watchwords, and you are their intended victims. Bestseller means nothing. Please do not be misled by this term.

Defrauding Patients and Insurance

I’ve written about this before, but the material requires updating because these practices continue to emerge and must be dealt with legally.

Today, we are still confronted by those who would deceive us and by doing so, become extremely wealthy, but the consequences for the people who come to them can be fatal. These individuals sought help after they believed there was no help from traditional sources of medicine or therapy, and they came wanting to believe that these “healers” offered the only hope for these patients.

Now, the curtain is being pulled back, and lawsuits and legal battles are being fought as some people have died. One man has now been charged with more than one incident of manslaughter when he advised someone to stop taking their insulin and instead use his “slapping” therapy. The man died.

Federal charges say a woman from Minnesota sold a fake “microcurrent therapy” device across the country that she said could fix almost any illness or condition but actually burned or hurt people who tried to use it

Not only are these fake healers being uncovered, but those who promote unprofessional therapies that any professional organizations do not recognize are being outed, too. Unfortunately, once their papers were published, too many people readily picked them up and used them as references in their papers.

Can you imagine that up to 10,000 professionally published papers had to be retracted for various forms of data manipulation or outright fraud? This form of publication pollution takes time to discover, but once it is discovered, we know that the damage has been done to too many people.

One form of alleged therapy is conversion therapy, which claims to change people’s sexual orientation from homosexual to heterosexual. Every professional organization has debunked this, and it is no longer viewed as valid by anyone but the practitioners who make money from it. How many people have been psychologically damaged by this therapy that perpetuates feelings of shame?

There are no magic healers out there, but they will continue presenting themselves as such, and it is up to consumers to check everyone’s background carefully. Criminals are always looking for new ways to make money and unfortunate, hopeless people on whom to prey.

The post Psychotherapy Shouldn’t Be Fatal, But Lethal Fraud Still Exists appeared first on Medika Life.

The complex relationship between medical diagnosis, treatments, and insurance reimbursement has sparked discussions on the accuracy and moral implications of medical procedures. This article examines how insurance reimbursement may affect medical diagnosis and treatments, as well as the stress it might place on both patients and healthcare professionals.

Start with one example I witnessed recently when a patient was going over their physician’s report after a visit and a medical test. The patient was shocked to see a diagnosis of neurodegeneration when the patient had never been told of that diagnosis. A brief discussion with the provider disclosed that it is often the case to indicate a diagnosis for which both the patient and the provider will receive payments. But even honest mistakes in billing can have dire results for practitioners. But what is known as “upcoding” is definitely not a mistake.

And in some hospitals, this has become the MO. But action is being taken to address this practice which may result in medical fraud by utilizing non-existent medical conditions for billing. The current action is by way of a bill, temporarily named “No Upcode.”

There’s also a problem here because not every disorder may be accurately reflected in the allowable billing codes from insurance companies or the government. Neurodegeneration may be another way of describing a medical issue that is not a major medical illness—or am I wrong here? There may be thousands of medical disorders that are NOT in the codes, so what does anyone do? Yes, you look for the closest code and use it, but it may be a frightening one or one that will affect future treatment.

How will this play out if the patient needs some type of emergency care in the future and is sent to an unknown medical facility? Reviewing the records, the medical team will not have accurate details of the patient’s prior health. Additionally, when software like EPIC contains false information, such as a medication issue that never existed and appears to be unfixable, it may be of no use. I know people who have tried for years to get their EHR errors fixed, and everyone claims helplessness on the issue, including hospital IT personnel.

On behalf of a patient, I contacted the health commissioner of my state, who assured me she would look into the issue and get back to me. That was about four months ago, at the time of this writing. I haven’t heard from her, and the patient is concerned about unknown issues that may arise if I contact this woman again.

So now we’re at a standstill after six years of trying to get the hospital in question to fix the error. BTW, medical records don’t have to be maintained after seven years at which time they can be destroyed. And medical malpractice is usually limited to two years for filing a complaint, but there are state differences and there may also be “discovery” issues involved.

Anyone wishing to contact their state’s health commissioner can do so at this link.

Not limited to medical care, I have heard clinicians indicate that, when family therapy is indicated, the therapist will note that the IP (identified patient) is the mother. She, then, is saddled with diagnoses that make her the bad apple in the basket, even though it’s the family unit that is in need. Is this ethical? It seemed that didn’t matter because reimbursement was the object and it was standard practice.

For clarification, let’s go over a few details. The basis for choosing a patient’s best course of treatment is their medical diagnosis. The connection between a diagnostic and insurance reimbursement, however, might occasionally have unforeseen results. Healthcare professionals are forced to balance their attention between the clinical features of a patient’s condition and making sure the diagnosis meets the requirements for insurance coverage. This may occasionally cause the emphasis to shift from strictly clinical issues to making sure the diagnosis is “billable.” If this sounds a bit troublesome to you, we’re in the same boat.

Insurance reimbursement, therefore, has an impact on healthcare professionals’ treatment decisions. Treatments that are more likely to be reimbursed in some circumstances are given preference, sometimes overshadowing those that could be better suited or more effective for the patient’s condition. As a result, it is possible for financial concerns to unintentionally take precedence over patient care, creating concerns about the morality of medical decision-making.

Patients may experience a great deal of stress as a result of insurance reimbursement and medical care. Not knowing whether an insurance company will pay OR deny a claim for a particular diagnosis or course of treatment can cause anxiety and worry. Many patients struggle with issues like “Can I afford the recommended treatment?” and “What if my insurance doesn’t cover it?” This uncertainty may discourage patients from seeking early medical attention or pursuing necessary therapies, which could eventually be harmful to their long-term health. Harmful seems to be putting it mildly because patients may forestall treatment and die because they believe reimbursement will be (or has been) refused. How much is a life worth?

Patients without comprehensive insurance may feel more stressed because they are aware of the close connection between their financial situation and their healthcare decisions. How many healthcare facilities depend on reimbursement for care, and how do they convey this to their staff? How often have you heard that a hospital is recruiting someone because they have a very large caseload and, therefore, ensure more-than-adequate funding for that person and their staff? How much charity care is provided?

When dealing with chronic or serious medical illnesses that call for regular treatments and interventions, this stress may be very acute. Patients may also feel pressured to make health decisions that are in line with what their insurance will pay for, perhaps compromising the best possible care in the process.

Patients may have significant administrative burdens while navigating insurance policies, coverage restrictions, and claim denials. Claims denials, too, are a hot topic since we know that some companies are using AI for denying claims. It reminds me of a physician who was making decisions on Social Security Disability benefits. Most clinicians take at least one-half hour per claim, but this man claimed he did 600 in an hour and was making an extraordinary amount of money doing it. Who was checking on the denials he was, most probably, making automatic denials?

Having trouble comprehending insurance terminology and being concerned about unforeseen out-of-pocket costs can cause frustration and bewilderment. As a result, patients may spend significant time and effort attempting to understand insurance-related issues, which would otherwise be focused on their own health.

Medical diagnoses, treatment choices, and insurance reimbursement are intricately linked, with significant ramifications for patient care and healthcare delivery. Recognizing insurance reimbursement’s possible effects on patient well-being and healthcare professional stress is critical because it helps keep the healthcare business alive.

Stakeholders can work toward a more harmonious strategy that emphasizes accurate diagnoses, efficient treatments, and overall patient health by acknowledging the ethical problems presented by this connection and promoting patient-centered care.

The post Is the Diagnosis Correct, or Is It a “Billable” for Charges for the Clinician’s Services? appeared first on Medika Life.

While it is seems that these denials are random in nature – and many times they really are – and there does not seem to be any way to completely avoid them, there is one strong defense against these denials: our documentation in the medical record.

The only thing that we can do to strengthen our cases against denial is proper documentation. This is especially true when the acuity of the patient may be borderline or – most especially – when the length of stay is relatively short. I interviewed an insurance company medical director, and he told me, “Oh we love those one day stays…” He said that because it is fodder for a denial in payment, and it sets off a lengthy process to get these denials overturned.

We need to document accurately and properly. We need to take the time to document our thinking process, and explain why we are doing what we are doing in the record. At the time we see the patient, it may be self-evident to us. But, when looking at the record months or even years later, it is not self-evident to the person reviewing the chart.

This cannot be overstated. This cannot be overemphasized. Documentation in the record is everything. It establishes the proper diagnoses for the Diagnostic Related Groups (DRGs); it establishes the severity of illness for a specific patient case and hospitalization; it sets the reimbursement for services rendered to care for a patient; and if documentation is poor, it gives powerful ammunition for insurance companies to deny payment. This is not even mentioning the fact that good documentation protects you in medicolegal cases…(that’s another newsletter at some point).

Does this mean that insurers will not deny payment for cases with good documentation? Of course not. At the same time, with good, detailed documentation, it becomes that much easier to defend the care during a Peer-to-Peer discussion; it becomes that much easier to defend the care in an appeal letter; with good documentation, it becomes that much easier to defend the care to an Administrative Law Judge. Good documentation is everything, and poor documentation just makes everything that much more difficult.

Documentation. Documentation. Documentation. It is so so important that we document properly. Yes, we are all busy. And with today’s technology, it is so much easier to document well. In a few seconds, I can document an entire paragraph in the record. It is time very well spent, and in today’s healthcare environment, there really is no excuse for poor documentation.

The post Your Best Defense Against Denials: DOCUMENTATION appeared first on Medika Life.

It was a great conversation. During the conversation, a fellow physician remarked to me about a common clinical scenario: An elderly patient will present to the hospital emergency department looking quite sick. He has a urinary infection, acute kidney injury, altered mental status, and a low blood pressure. We evaluate said patient and aggressively intervene with IV fluids, antibiotics, and close monitoring. The patient greatly improves by the following day, and he is discharged from the hospital. It is a great patient care win.

The insurance company – weeks to months after the fact – will then send a denial notice to the hospital, refusing to pay for the care that was delivered because the “patient was not that sick” and did not warrant the inpatient level of care. And then the fight ensues, frequently enlisting Physician Advisors like me to argue the case for proper reimbursement.

There’s the rub, it seems. If that same patient had gotten sicker, developed acute renal failure and shock, needed invasive mechanical ventilation, and was admitted to the intensive care unit, there would be no question (one would hope) that the hospital would receive the proper reimbursement for all the care that was delivered. It is a strange and frustrating paradox, and it highlights an important point:

We do not get credit for being good clinicians.

There is no diagnostic code for “could have become septic if we didn’t intervene.” There is no DRG that says, “this patient is sick, and I can’t wait for her to get sicker.” There is NO WAY that I would EVER wait for a patient to develop organ failure so that I can definitively diagnose her with sepsis according to the Sepsis-3 definition. And yet, if I even smell sepsis on a patient, if I have the slightest suspicion that a patient is septic, I will aggressively intervene so I can prevent that patient from developing multiorgan failure and death.

And if I don’t get credit for that, then so what. Who cares. It is why I became a doctor in the first place.

At the same time, there is something we can do as clinicians to better tell the story about that sick patient upon whom we aggressively intervened. We can document our thinking process much, much better.

For example, for that patient scenario mentioned above, if we write in the medical record:

Assessment and Plan:

1. UTI

• Admit for IVF and IV antibiotics

This doesn’t really capture “how sick” the patient really was. It does not capture our clinical concern, our “gut feeling” that – if we do not aggressively intervene – the patient will get worse and develop “full blown” sepsis.

Contrast that with this documentation on the same patient:

“This is an elderly man with multiple comorbid conditions that place him at very high risk for adverse outcome and acute deterioration. He presents with a urinary tract infection, acute metabolic encephalopathy, acute kidney injury, and hypotension. All of these complications are likely related to the urinary tract infection itself. He looks quite ill on examination. If we do not aggressively intervene, he is at great risk for sepsis, organ failure, and death. As a result, he will be admitted to the hospital for close monitoring, IV antibiotic therapy, IV fluid resuscitation, serial laboratory assessment to monitor renal function, and serial reassessments.”

Now, if this patient gets better by the following day, the commercial insurance company may still deny the care for “lack of medical necessity” for inpatient admission. Yet, it is so much easier to defend the care of the clinician who wrote the second paragraph. This second paragraph better encapsulates how the patient appeared to the clinician and why the clinician decided to admit the patient as an inpatient in the first place.

It all comes down to documentation. It is the only thing upon which everyone – other clinicians, regulators, payers, third parties, and auditors (like myself) – relies: the clinicians’ documentation in the record. If it is poor, everything becomes that much harder.

Poor documentation makes it much easier for a commercial insurance company to deny medically necessary care. Poor documentation makes it much easier for an auditor to go back and deny this diagnosis or that. Poor documentation adversely affects so much in today’s healthcare world. In the era of EMRs, dictation, and technology, there is really no excuse for poor documentation.

Yes, it is true that we do not get credit for being good clinicians. We do not get more reimbursement if we do the right thing and aggressively treat a patient and prevent organ failure and death. If anything, commercial insurance payers may penalize us by refusing to pay for the care at the appropriate level deserved. It is annoying. It is infuriating. It is patently unfair.

We push back against this by properly documenting in the record what we are doing and why. And, at the end of the day, if we do right by that patient and prevent him from dying from sepsis, then that is a wonderful thing. It is why we went into healthcare in the first place.

The post We Get No Credit For Being Good Clinicians appeared first on Medika Life.

In previous articles, we have been discussing the various different types of reasons insurance companies deny payment for services rendered by hospitals to their patients. Perhaps the most annoying and frustrating for me is the “30 day readmission” denial. This is a denial in which payment is denied for a hospital stay that is within 30 days of a previous hospital stay. The allegation is that the patient was inappropriately discharged from the previous hospital stay, and thus the subsequent stay should be considered part and parcel of the first, what we call the “index,” hospitalization. I have seen these denials come through even with hospital stays three weeks later, even for a different reason. 

Now, the Centers for Medicare and Medicaid Services, affectionately known as CMS, also penalizes hospitals for excess readmissions within 30 days. It is called the Hospital Readmission Reduction Program, and it tracks the ratio of the predicted-to-expected readmissions to the hospital for the following conditions: (1) acute myocardial infarction, (2) chronic obstructive pulmonary disease, (3) acute heart failure, (4) pneumonia, (5) coronary artery bypass graft, and (6) elective total hip and knee surgery. If there are excessive readmissions to the hospital for patients with any of these conditions, payments to that hospital are reduced the following year. 

Some commercial insurance companies have taken the concept of this program to the extreme by denying payments for any hospitalization, for any reason, for any condition within 30 days. For example, if a patient is admitted to the hospital for pneumonia, and then suffers a heart attack three weeks later and admitted again for the heart attack, I have seen commercial insurance companies deny payment for that subsequent hospital stay, even though it had nothing to do with the previous one.

CMS claims this program “encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions.” This goal, of course, is laudable. Everyone wants the best quality care if they must be admitted to the hospital.

At the same time, a readmission to the hospital is completely unavoidable. Sometimes, as I mentioned previously, a patient suffers an unexpected complication such as a cardiac arrest. Sometimes, a patient is in a car accident and has to be admitted to the hospital. Sometimes, a patient does not follow medical instructions, such as taking diuretics to reduce total body volume for heart failure, and they present back to the hospital for another exacerbation of heart failure. Sometimes, it is unfair to penalize a hospital for something that is beyond its control.

At least, CMS tracks a ratio rather than an absolute number. The denials I am talking about here are absolute: a payer will simply deny payment because a patient is admitted to the hospital within 30 days. Even if it is 29 days, I have seen these denials come through. And, frequently, there’s absolutely no explanation as to why the denial occurred. 

Moreover, many times, the subsequent hospitalization is very long because the patient is extremely sick, such as suffering cardiac arrest and having brain injury due to lack of oxygen. To simply deny the subsequent hospital stay because it happened to occur within 30 days of a previous hospital stay is inappropriate and beyond frustrating. “Ensuring quality of care” by by making such a denial is disingenuous at best. 

It is one thing if a hospital, seeking to minimize length of stay, prematurely discharges a patient while they are still clinically unstable: for example, with an incompletely treated infection or still with significant heart failure. That hospital deserves to be penalized for a readmission. I can say, with a reasonable amount of certainty, that most hospitals do not fall into this category. 

Most hospitals try their best to treat the patients entrusted to their care in the most appropriate and efficient manner as possible. I can understand CMS’ readmission reduction program. The readmission denials I see coming from commercial payers are simply punitive and wholly unnecessary. 

It is unlikely that these types of denials will ever go away completely, especially given the presence of the CMS hospital readmissions reduction program. I can always see commercial payers pointing to the program as inspiration for their own 30 day readmission denials. At the same time, I am going to call out their callous and arbitrary nature. With all the challenges and challenging environments we in healthcare have to deal, needing to expend precious resources to defend denials such as these is truly baffling. 

The post From The Appeals Desk: The “30 Day Readmission” Denial appeared first on Medika Life.

Until now, you just sort of accept medical caregivers to be what it is, even if it frustrates you. But the time is rapidly approaching when you will expect an adequate period of time with your caregiver, that the caregiver will know you as a person and indeed know you as a person that is part of a family, a community, and a society. You will not tolerate any longer being treated as a “number,” a “case,” or as a “problem.” If you don’t receive the care as described, you will seek out care elsewhere.

An example of this is a friend, Rebecca, a physician’s wife, who developed breast cancer. She was seen immediately by a topnotch surgeon who did her biopsy and then lumpectomy in a very timely manner with plenty of discussion and “hand holding,” She then went to a highly regarded medical oncologist with the expectation that she would receive her drug therapy and radiation therapy at that individual’s hospital. She knew that the oncologist was well trained and very competent. However, the physician seemed pleasant enough but not engaging and not really focused on my friend as a person.

It seemed as though she went through a “checklist” of information in a “rote-like” manner. Rebecca felt like she was just “one more” breast cancer patient rather than an individual with a particular problem. She felt that perhaps the physician was just having a tough day or that she, the patient, was being seen at the end of a long line of other patients that day. But no matter, this was the physician who was to be her primary caregiver concerning an issue of utmost importance to her. The result: My friend went elsewhere for her medical oncology and radiation therapy care. The basic message, of course, is that patients now want and expect not only competency but also personal and professional care and will both pay for it and demand it. A bit of empathy doesn’t hurt either.

Compare that story to this one. A couple, Bob and Ruth, went to a small Caribbean island for a two-week vacation. On the last day of their vacation, the husband had a heart attack. Bob was taken to the island’s small 25-bed hospital. He and Ruth, who works at a major hospital in a patient care/advocacy profession, were immediately concerned that the level of care would not be up to the standards that they would have expected in their large U.S. city. However, what they found, to their obvious pleasure, was a highly skilled physician who was also highly interactive with the two of them. He did the appropriate diagnostic tests to demonstrate that it was a heart attack and then began the proper medical therapy. Concurrently he arranged for Bob’s air transport to a major Florida hospital.

Meanwhile, others at this small hospital helped Ruth cope with her concerns and deal with some practical issues of getting checked out of the hotel, returning the rental car, arranging medical evacuation flight and all the other details that needed to be done. In short, they looked after her as well as her husband. Ruth cannot speak highly enough of the care that her husband received.

Both of these patients were “connected” to the healthcare professions. So, if you think compassionate, attentive care always comes to such individuals, think again. Years ago, doctors offered their colleagues and families “professional courtesy.” No more. That will not change, but whether the doctor or family member is a patient or not, they will expect compassionate, attentive care just like everyone else. They may be the ones to push the system the hardest and, at the same time, “look in the mirror” at their own practice patterns and initiate change. Change will occur but never as soon as desired.

Both of these stories also illustrate the issue of complex, chronic disease. These diseases do not go away; they can often be cured, but the possibility of a subsequent problem [heart failure] or recurrence [cancer] is real. Many chronic illnesses will be with the patient for life. They require many different practitioners with differing skills to help care for them, which all need coordination.

But in America today, care for these complex, chronic illnesses, which consume more than 70% of all medical care expenditures, are definitely not addressed in a coordinated manner except in a few centers and practices. This means that the care is not up to the quality levels it could be given our knowledge base and our excellent practitioners, and it also means that the costs are much too high. We need to find a way to change our delivery system so that it delivers coordinated, compassionate, and safe care to individuals with these complex, chronic diseases.

Here is a “problem” which everyone needs to understand. If you are on Medicare, Medicare sets the payment for the doctor. He or she cannot bill you more than what Medicare allows. So, if you say to your doctor, “Look, I’d like to spend some more time to fully have you understand my situation or so that I can better understand your advice,” the doctor can say “OK” but Medicare will not pay any more for that extra time and the physician, by law, cannot bill you for the extra time spent. If you were doing a new will and wanted to spend more time understanding what the lawyer was recommending, the lawyer would say “OK,” but both of you would know that you would be billed for the added time. With Medicare, you don’t have that option.

Consider Renee. A few years ago, she asked me for the name of a physician who would give her the time needed for her situation as an older single lady with multiple chronic problems not being fully addressed by her all too many doctors. I suggested Gary Milles, MD MPH, who has a “concierge” practice. He charges a flat fee of $1850 per year and, in return, is available by cell phone 24/7, text, and email. He has only about 490 patients, unlike his original practice with 2700. So, he can offer same or next-day appointments lasting as long as needed.

Each year he does a very comprehensive evaluation lasting two hours, including multiple blood tests, a vision, hearing, and pulmonary analysis at no added charge. Importantly, if a specialist is needed, he will call that doctor directly, explain why he is referring you, and ask for a prompt appointment. That means you will be seen much sooner than if you called that doctor’s office and the doctor will understand why you are there when you come for your appointment. This all makes a big difference in care.

“You aced it when you referred me to Dr. Gary Milles! He has been terrific for me. First, he found out why I’ve had very high BP for four years, e.g., 250/160. Then, instead of all those blood pressure pills, he stopped them and put me on something less powerful and with less side effects and stopped some supplements recommended by a different doctor, adjusted my diet, and gave me some suggestions on stress management. As a result, blood pressure is now OK. So far, so good….we had to make only one adjustment after several months!

“But now I need to see a pulmonologist. The one he recommended did not work out. Great background and experience, but when I had my first visit, things started out poorly (very impatient and rude with me) and quickly spiraled downhill. He definitely is not for me. I will ask for another option.” Dr Milles was thankful that she reported the poor caring and sent her to another pulmonologist who had the appropriate medical but also personal skills. The first pulmonologist will not be getting referrals in the future.

This change to “patient first” is occurring slowly, beginning with primary care physicians, using the direct primary care or concierge models, regaining the time needed to give adequate, expert attention, and, when necessary, coordinating multiple specialists. This means much better quality of care, coordination when needed, all tied into genuine compassion and caring. In that way, it will be a return to my physician grandfather’s time when treatment options were limited. Empathy and caring will be uppermost while still preserving the incredible advances modern science has brought forth. It will mean better care, less patient frustration, less doctor frustration and burnout, and a huge reduction in total costs as an added, very important bonus.

It is a contract between the doctor and patient; no insurer is involved. But of course, if the patient does not feel well treated, the contract is voided, and they will move on to someone else.

The post Consumerism in Healthcare appeared first on Medika Life.

Scott Wiener made a startling revelation at a spring legislative committee hearing: “I was in the hospital. I experienced the most intense abdominal pain that I could even imagine.”

The Democratic state senator recalled crawling up the stairs to his landlord’s apartment last July to get a ride to the hospital.

The San Francisco lawmaker also disclosed to his colleagues on the Senate Health Committee that he has Crohn’s disease, a chronic autoimmune condition that causes inflammation in the digestive tract. His body, he said, wasn’t responding to his medication, which led to abscesses in his abdomen and a weeklong stay in the hospital.

Wiener is a youthful, lean 52-year-old who is known around the Capitol as an energetic workaholic. It’s a reputation he has had since his early days as a San Francisco supervisor.

He is known for his progressive proposals on housing affordability, safe injection sites, mental health, and sentencing reform. Wiener is also an intensely private lawmaker, who, by his own admission, isn’t the type to “personalize these things.”

He opened up after some Republican lawmakers and health insurance lobbyists questioned the cost of one of his bills during a committee hearing in April. SB 853 would require state-regulated insurance companies to cover a denied prescription while the patient appeals the decision if a patient has previously taken the drug — even if it’s at a higher dose than the FDA has approved or in a different form than was previously prescribed.

The clause about drug dosage and form is especially important for patients who have an autoimmune disease, such as Crohn’s, because they sometimes need a higher dose of a medication than the FDA recommends. Or the medicine might work better for them in injectable form than as a pill.

Patients who are denied medicine often go without it while they appeal, a process that health plans say generally takes 30 days. Some patients, however, say it can take months.

Under his bill, if he ever had to contest his health plan’s decisions about his medications, Weiner told his colleagues, “I could get the proper dosage during the appeal so that I wouldn’t have to miss more health committee meetings.”

But Jedd Hampton, legislative affairs director for the California Association of Health Plans, said the bill would give patients “unfettered access to prescription drugs,” which could lead to abuse and addiction. “We are strongly concerned that stripping health plans of the ability to provide clinical oversight and access to certain drugs may cause potentially adverse reactions and real harm to our enrollees,” he said.

The Senate approved Wiener’s bill 39-0 last month. It is awaiting a hearing in the Assembly.

Wiener sat down with KHN senior correspondent Samantha Young to talk about what it’s like to live with Crohn’s disease, his hospital stay, and how that experience informs his work. The interview has been edited for length and clarity.

Q: How does Crohn’s disease affect your life?

I have had it for 33 years, and I’ve been lucky that, other than last year, I just deal with periodic pain. But last spring, I started getting more symptomatic, and I was hospitalized for one night at the end of June with pain. Then a month later, on a Tuesday night, getting into bed, all of a sudden, the only way to describe it, it was like an electrical storm in my abdomen. The most severe pain I have ever felt.

The hospital did a scan and found multiple abscesses in my abdomen. I was in the intensive care unit for three nights and in the hospital for a week. They had to drain abscesses, and I was on heavy antibiotics. I had a reoccurrence in September, and I had to go back to the hospital for four days. But now it got all cleared out, and I’ve been doing great since then. I feel lucky.

It’s never really affected my ability to be a workaholic, my ability to just live my life, travel, vacation. I feel very privileged. There are other people with other autoimmune diseases and Crohn’s who are much more impacted.

Q: How do you monitor your Crohn’s?

After I left the hospital, I began consulting with an infectious disease specialist. I know what to look for, so hopefully this will never happen again. I know I need to go to the hospital if I have an unexplained fever with some pain and I’m testing negative for covid-19. For a lot of people, if you have an unexplained fever for a few days and you just don’t feel well, you let it go. For me, I need to go to the hospital and have a scan done just to make sure I don’t have an infection.

Q: There are so many chronic health conditions that require specialty care and drugs, which can be very expensive. Have you ever had trouble getting coverage for them?

I was always on common generic medicines, but then the two times I had to go on specialty drugs, I’ve had two opposite experiences. The first time, my insurance company said I had to first try and fail the steroid prednisone. Well, anyone who knows anything about prednisone knows that it is a last resort. Prednisone has so many side effects, and long term, it can cause a lot of problems. It was just shocking to me and my doctor that the insurance company said you have to try and fail.

Then, when my doctor went to switch me to what I’m on now, it was approved within 24 hours. It was as easy as could be. So I’ve experienced amazing health plan response and also really challenging response.

Q: What does that tell you as a lawmaker about the way our health care system works?

Sometimes the system works really well, and sometimes it doesn’t. And if you are not the kind of person who can advocate for yourself or you don’t have your primary care physician able to advocate for you, you can really have a bad outcome.

Q: What have you and other lawmakers done to address that?

We do a lot of work around health plan accountability. I’m carrying another bill, SB 858, that would increase fines for health plan violations. During my entire experience last year, with various hospitalizations, my health plan was terrific. Everything was very prompt, and we always had a nurse follow up with me after I left the hospital. But people do fall through the cracks — sometimes mistakes are made in terms of denying coverage.

I’ve supported and co-authored numerous pieces of legislation to lower prescription drug costs. I’m very fortunate that I have excellent health insurance, but a lot of people don’t. I haven’t had copay problems, but there are people who had to pay huge amounts of money just to get medicine because coverage doesn’t kick in until they pay $5,000. It makes me very sensitive to those cost issues. And I was a proud champion and co-author of AB 1400, Assembly member Ash Kalra’s single-payer legislation.

Q: Does your personal life influence the bills you sponsor?

My personal experience certainly influences my perspective on life. My personal experience as a gay man, as a patient, and in the community in general. It’s true for any elected official, and that’s why it’s important to have officials with lots of life experience because I think it makes you a better representative.

Q: Your bill came under tough questioning from some Republican lawmakers, but that shifted after you shared your story. Do you think personal stories like yours carry weight with your colleagues and the public?

Yeah. I was really grateful that it got bipartisan support. And I think for some of these issues, there’s really no reason for it to be partisan.

As elected officials, sometimes we’re viewed as caricatures of human beings. We’re human beings who have the same challenges that other people do — challenges parenting or having a sick family member. We’ve had members who have had to deal with difficult family situations or health situations. I think it’s good for the public to know that.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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