Straight Talk Tuesday

Is anyone else out there noticing that they have to call for a “peer-to-peer” every time they want to get an advanced therapeutic approved for patients with Medicare HMOs? I try to be very judicious in my use of advanced therapeutics like cellular products and hyperbaric oxygen therapy. I follow the Local Coverage Determinations (or National Coverage Determinations if applicable) to the letter. But, it doesn’t matter – I need a peer to peer phone call. The question is, how many of those am I willing to make a day? How many of those calls is it realistic that I will make a day? I think I have decided that one or two of those phone calls day is the maximum for me. So, if I realize that I have a lot of patients needing advanced therapeutics and they have Medicare HMOs, I delay ordering it.

I’ve also been keeping track of how many wasted visits the Medicare HMO patients have had due to delays in authorizing needed interventions, supplies, or devices. For example, it took 6 months for one patient to get a new CROW walker for her severe Charcot deformity. I did a peer-to-peer call but the Chief Medical Officer of the insurance plan told me that off-loading a diabetic foot ulcer was not part of wound care. There are delays of weeks waiting on dressings because of the cut-rate durable medical equipment company they use which I would LOVE to call by name here but won’t – takes so long to get supplies to the patient they NEVER have the dressings they need during their course of care. (I have to use samples of dressings or old dressings donated by patients because otherwise they simply will go weeks without anything to use). I can’t get needed compression garments from the Medicare HMOs. I’m working on a report for one Medicare HMO to tally up the visits to the wound center that could have been avoided if they had authorized what the patient needed when I asked for it. This type of inefficiency among the Medicare HMOs is actually likely to make care MORE expensive but I’m not sure what to do about it. I’m also not sure what to do about the fact that at some point each week, I just stop making peer-to-peer calls because I feel like I have done enough.

Last year my husband became eligible for Medicare. He’s got a lot of chronic illnesses and is not doing well. His relatively healthy brother suggested that he select a Medicare HMO to save some money. Both my husband and his brother were surprised at how much emotion I showed when I said, “NO way is my husband going to have a Medicare HMO.”  Whether a Medicare HMO patient gets the wound care services they need is currently being decided by my level of frustration, fatigue or availability for yet ANOTHER peer-to-peer” phone call. I don’t want to think my husband’s care will be held hostage in the same way.