Patti's Blog - Advocate for Elders, People with Disabilities and Their Families

Families fight insurers for life-saving care for loved ones with mental health conditions

CBS NEWS - October 22, 2019, 7:46 AM

 

Every year, an estimated 1 in 5 American adults experiences mental illness. When it comes to insurance coverage, the law is clear. The federal Mental Health Parity legislation passed in 2008 requires health insurers to provide at least equal coverage for mental health conditions, as they do for medical and surgical care. But as CBS News' Dr. Jon LaPook found out, some families still have to fight to get the life-saving care their loved ones need.

In 2013, Brian Cada's 15-year-old daughter Nicole took her own life. A year and a half later, his younger attempted suicide. She was 14. 

"She was unable to really process the death of her sister. She kept it inside," Cada said.

Residential treatment was denied. A less intensive level of care was approved. 

"The hospital ... said what that translates to is your daughter has not failed often enough to get a longer-term treatment center," Cada said.

After a second suicide attempt, she was approved for residential care. After three weeks there, the clinical staff described "an increase in suicidal ideation," and that she "clearly" met criteria to continue treatment there.

But just a few days later, the insurer, United Behavioral Health (UBH), part of UnitedHealth Group, wrote: "the services asked for are not medically needed."

"They were basically protecting their profitability," Cada said.

Cada could only afford another three weeks.

"It takes time. And because she didn't have that time, she went back into a withdrawal situation," Cada said.

Sylvia Tawse has kept a meticulous record of her son's mental illness and her efforts to get his treatments covered.

"My son was homeless three different times... because he was discharged from the hospital and there was no program for him to go into," Tawse said, adding, "Nine of 10 times, you're getting denied the kind of care that you know your loved one requires."

He has schizoaffective disorder, diagnosed in his teens, and has been hospitalized more than a dozen times. He now works with Tawse and her husband on the family's organic farm. They have depleted their retirement savings paying for his mental health care.
 
Tawse played us this 2016 voice mail from a care coordinator discussing how many more days would be covered at a residential care facility. "If his symptoms have worsened — " Tawse stopped the tape. 

"'If his symptoms have worsened'… they're letting you know the only chance of greater care is if your child's symptoms get worse,"  Tawse said. "And then you end up... where you're oddly, slightly hoping that something worsens."

"So, you hear the suggestion that your son get Medicaid from the UnitedHealthcare people?" LaPook asked.

 

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The Pressures of Having an Invisible Disability

Shelby Gottschalk - The Mighty - October 14, 2019

Having a disability is hard. It can be challenging in different ways when it’s an invisible disability. What exactly is an invisible disability? It’s defined as a disability that one can’t see. Most people don’t consider that when making assumptions. We tend to only notice what the eye can see.

For example, one might assume a person is sick because they lack hair. “She must be on chemo.” Or what about the boy in the wheelchair with no legs? Do people question his need for a mobility device? Most people would answer no. However, when those of us with invisible disabilities need to use such aids or accommodations, we can be doubted and looked down upon.

Pressure #1: One of the main pressures I’ve come across as someone who has an invisible disability is to appear “sick” so people don’t question the legitimacy of my illness. If I know I’m going to the grocery store and I might need to use the electric scooter because my heart condition is flaring, or my legs are sore from the infusions I had last night, I might not put makeup on. I might decide to let the world see the dark circles under my eyes and my overly pale skin. That way, when they see me riding that darn scooter while I purchase my carton of eggs, they might not send me judgmental glares and talk under their breath about how I’m taking it from someone who “might need it more” than me.

Related:​ The 9 TV Characters I Love to Watch Because of Their Chronic Illness or Disability

Pressure #2: Accessible parking stickers have become the bane of my existence. I have heard many horror stories from people like me who have gotten a disability parking sticker from their doctor but have been condemned for using it. There have been notes left on cars from people saying, “How dare you take that parking spot from someone who is actually sick or disabled?” Even physical altercations have ensued from such instances.

I feel pressure to park in a regular parking spot like everyone else and tuck the disability permit in the pocket of my car door to gather dust. I don’t want people to look at me weird because they see me walking into the store upright and on two legs. They don’t know that my lung function can drop severely from walking long distances and result in my loss of consciousness. I don’t want to get in a fight. I just want to get my eggs.

 

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Formulary Changes to Medicaid Inhalers Worsens Pediatric Lung Function

OCTOBER 20, 2019 - Kevin Kunzmann - @NotADoctorKevin

 

Changing inhaler use due to insurance formulary changes can reduce the control of pediatric asthma, according to new prospective findings.

In new data presented at the CHEST 2019 Annual Meeting in New Orleans, LA, investigators reported significant declines in forced expiratory volume (FEV) and forced expiratory flow (FEF) among pediatric patients with asthma who switched inhaler forms due to discontinued Medicaid coverage.

The findings, which surround a 2016 discontinuation of beclomethasone dipropionate (BDP) in favor of mometasone furoate (MF), provide tangible understanding of the insurance coverage change’s effect on patient asthma control—which adds to the already-understood narrative of patient and caregiver confusion at the time of the discontinuation.

“We sought to characterize the objective impact of this change by examining prescription patterns and patient’s lung function pre- and post-change,” investigators, led by Scott Bickel, MD, wrote.

Bickel, of the University of Louisville, conducted the retrospective chart review of children aged 6-18 years old with asthma from a large, university-based general pediatric clinic that’s comprised of a predominately Medicaid-covered population.

Qualified patients had a spirometry both before and after the 2016 formulary change, which discontinued traditional metered dose inhaler (MDI)-available BDP in favor of an MF formula available in both MDI and dry powder inhaler (DPI) form.

Prior to the formulary change, 67 of 68 (98.5%) children on inhaled controller therapy were using MDI. After the change, just 39 of 65 (60%) were using MDI. Of patients initially on BDP via MDI, 24 of 59 (41%) had switched to a DPI after the change. Of those 24 patients, mean predicted FEV₁ dropped from 99% to 89% (P = .01).

Investigators also observed a statistically significant decline in FEF25-75, where the mean predicted patient score fell from 89% to 77% (P = .04). Of patients to remain on an MDI, however, investigators found no statistically significant change in lung function—FEV₁ mean predicted score was 101% pre-change, and 98.9% post-change (P = .68).

Bickel and colleagues concluded changes to inhaled corticosteroid formulary can negatively affect pediatric lung function, especially when the formulary change involves a different type of inhaler.

“This is likely secondary to patient and family confusion on proper device use owing to a lack of adequate timely education intervention as well as the inability for some younger children to use DPIs,” they wrote.

The team suggested insurance formulary changes be more clearly and promptly communicated to physicians, pharmacists, and  families prior to their taking place—and that pediatric difficulty with such changes be better considered in the first place.

The study, “Do Inhaled Corticosteroid Formulary Changes Impact Control in Pediatric Asthma?” was presented at CHEST 2019.

 

 

 

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Nursing Homes in Michigan Could See ‘Devastating’ Medicaid Cuts of $37M This Year

By Maggie Flynn | October 20, 2019

 

Skilled nursing facilities in Michigan could see their Medicaid reimbursement cut by tens of millions later this year if the state moves forward with a proposed change that would take effect November 1.

Crain’s Detroit Business first reported the news.

Under the plan, Michigan would make changes to the ceiling for costs that SNFs can claim for reimbursements, according to a proposed policy draft from the Michigan Department of Health and Human Services (DHHS), issued on September 30. Nursing facilities, county medical care facilities, hospital long-term care units, and ventilator-dependent care units would be affected.

Comments on the proposed draft are due on November 4. If the changes take effect, they would be implemented for cost-reporting periods ending on or after November 1.

In Michigan, SNFs are reimbursed under a cost-based system, where SNFs must file cost reports summarizing how much they’ve spent on caring for residents, Health Care Association of Michigan CEO Melissa Samuel explained to Skilled Nursing News. The state looks at Medicaid days and rates for all providers in the state, and all costs are capped at the 80th percentile of operators.

The new policy would change that, capping costs and rates at the 65th percentile. The cut would represent about 20% of Medicaid reimbursement, or an average of $11.45 per resident day, Crain’s Detroit reported, citing nursing home officials.

The change is modeled on a proposal that was in Michigan Gov. Gretchen Whitmer’s executive budget recommendation, but was eliminated by the Republican-controlled legislature, DHHS public information officer Bob Wheaton told SNN via e-mail.

“The Legislature’s budget left significant holes in the MDHHS budget, and Gov. Whitmer asked MDHHS to look for cost efficiencies to fill those holes,” Wheaton said. “This policy change was one of those cost efficiencies.”

 

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Vietnam veteran in hospice care had a simple request: To reunite with his dog one last time

 James Clark - October 21, 2019 at 10:40 AM

 

 

John Vincent, a 69-year-old Vietnam veteran in hospice care had one final request: To say goodbye to his best friend, a 5-year-old Yorkie named Patch.

 

After Vincent entered hospice care last week at the Raymond G. Murphy Veterans Affairs Medical Center in Albuquerque, New Mexico, he had to put Patch up for adoption because he had no family in New Mexico. But when he told social workers at the medical center that his last wish was to spend some time with his pup, they happily obliged.

"When the request came in, it was an immediate 'absolutely,' and let's do whatever we can to get it done," Albuquerque Animal Welfare director Danny Nevarez told the Albuquerque Journal, which first reported the story. "It was as simple as getting Patch over here."

The emotional reunion, which quickly led to a string of viral news stories from local and national publications, left few dry eyes in the room. As Vincent stroked Patch's wiry brown fur he said "Yeah, that's me, that's daddy... Are you so happy to see me? I'm so happy to see you."

Vincent told the Albuquerque Journal that he was born and raised in Montana, and enlisted in the Marines as a young man where he saw service in Vietnam during his three years in the Corps. After the military, he moved around, working blue collar jobs, before eventually retiring in New Mexico, which is where he met Patch.

A neighbor's dog had a litter, and "he was the smallest, and I wanted one that could ride on my bike," Vincent told the Journal. "The only hair I had was on my chin, which was called a patch. … And he had a little white patch, so we were the patch brothers."

 

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A Will Without Ink and Paper

By Paul Sullivan  - Oct. 18, 2019

 

The practice of creating a will to dispose of your assets dates to ancient Greece. The will as most people know it in the United States can trace its form to 17th-century British law.

For centuries, one requirement for a will to be valid, whether it was written by hand, drafted by a lawyer or typed out on a home computer, was that it had be signed with ink in front of witnesses.

There have been a few exceptions — one litigator recalled a farmer who scrawled his wishes on the dusty tractor that had run him over — but the process has otherwise been largely unchanged since it was conceived.

But a movement is growing to legalize e-signatures for wills and trusts, which would allow people to complete the whole process online, without a lawyer or notary present. The driving force behind this change is the Uniform Law Commission, a nonprofit organization that proposes laws for states to adopt. Last month, the commission drafted the Uniform Electronic Wills Act to serve as a model for states.

Nevada and Indiana already have laws allowing e-signatures; Florida and Arizona are set to adopt similar laws next year. Other states are expected to follow the commission’s guidelines.

Online wills are nothing new. Rocket Lawyer and Legal Zoom offer them, along with scores of other legal documents and services. FreeWill, which I wrote about last year, put a charitable spin on will creation, creating a platform to name charities in a will. A company called Tomorrow is trying to make legal documents like wills more engaging by asking people to go through the process with partners or family members.

 

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Molina To Buy New York Medicaid Plan

Bruce Japsen - Oct 16, 2019, 09:54am

 

Molina Healthcare has agreed to buy a health plan in New York for $40 million in cash in a move to expand its Medicaid health benefits operations in the state.

Molina said Wednesday it has signed a deal to “acquire certain assets” of YourCare Health Plan, Inc., a nonprofit unit of Monroe Plan for Medical Care. The deal will bring 46,000 Medicaid members in seven counties in the Western New York and Finger Lakes regions, Molina said.

The deal will bring Molina revenue amid growing competition among rival health plans that are consolidating to gain market share. It’s the latest nonprofit health plan to entertain a takeover in New York. Last year, Centene bought a much bigger nonprofit plan in Fidelis Care for $3.7 billion.

Molina said YourCare’s estimated premium revenue for the full year 2019 is approximately $285 million. The deal is expected to close in early 2020 pending regulatory approvals.

Though a small acquisition given Molina generates about $4 billion in premium revenue every quarter, it’s a sign the health insurer is delivering on its promise to increase cash flow and grow its businesses in the second year of new management. Joseph Zubretsky was named Molina’s CEO two years ago amid a restructuring of the company following the ouster of the Molina brothers who at the time were the top two executives at the company. 

“This agreement represents an exciting opportunity to build upon our existing operations in New York and expand into new service areas,” Colleen Schmidt, president of Molina Healthcare of New York said in a statement. “Molina is excited to partner with Monroe and MP CareSolutions on select services to facilitate access to quality health care and ensure a seamless transition for members and providers.”

 

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Is smell enough to justify search warrant? Bloomfield Township man appealing decision on marijuana case

• By Aileen Wingblad awingblad@medianewsgroup.com; @awingblad on Twitter - Oct 15, 2019 Updated Oct 16, 2019

 

Nearly a year after voters approved adult use of recreational marijuana, Oakland County resident Kevin John Carlson continues to fight a possession/intent to deliver case, which he believes stems from a search warrant that should never have been granted.

Carlson, 30, was charged in early 2018 after police searched his Bloomfield Township home and reportedly found marijuana and other evidence — months prior to cannabis being legalized in Michigan. At the time Carlson was a registered marijuana patient and caregiver, legally allowed to have a certain amount of cannabis.

The magistrate who issued the search warrant — based on police reportedly smelling marijuana outside the home — was wrong to do so because it wasn’t based on probable cause, Carlson claimed.

When police executed the search warrant, they reportedly found much more than the allowable amounts — 155 pounds of marijuana in packages and jars, scales, $82,000 in cash and other evidence to pin the possession and drug delivery/manufacturing charges on Carlson. Yet Carlson’s trial in Oakland County Circuit Court was put on hold last year while he appealed Judge Phyllis McMillen’s ruling there was no issue with the search warrant, and the evidence that turned up was admissible.

Carlson’s claim that the smell alone wasn’t sufficient for a search warrant recently got shot down by the Michigan Court of Appeals, who sided with McMillen’s decision not to quash the evidence.

The opinion, in part, states: “the strong odor of marijuana that the officer smelled provided a substantial basis to infer a fair probability that contraband or evidence of a crime would be found inside the defendant’s home.”

The court further found that the 2008 Michigan Medical Marihuana Act didn’t shield Carlson from the search, stating “the police were not obligated to determine, before obtaining a search warrant, the legality of the marijuana-related activities inside the defendant’s home and whether the defendant’s activities complied with the MMMA.”

 

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UM asks higher court to intervene in life support controversy

Karen Bouffard, The Detroit NewsPublished 6:01 p.m. ET Oct. 14, 2019 | Updated 1:33 p.m. ET Oct. 15, 2019

 

The University of Michigan has asked the state Court of Claims to intervene in the case of 14-year-old Bobby Reyes, whose parents are waging a court battle to keep him on life support against the advice of C.S. Mott Children's Hospital doctors who have declared the boy brain dead. 

A second medical opinion obtained by the Reyes family and viewed by The Detroit News maintains that the boy is not brain dead and could perhaps recover consciousness. 

In a petition filed Friday in Washtenaw County Circuit Court, the university argued that Washtenaw County Trial Court Judge David Schwartz did not have jurisdiction to issue a restraining order Friday that is blocking the hospital from discontinuing the boy's life support. The hospital's doctors have diagnosed the teen as brain dead.

The parents are "very religious," said family attorney Bill Amadeo of Ann Arbor, and want to give Bobby every possible opportunity to stay alive.

"We have at least one hospital, possibly two or more, that will take Bobby if he had a tracheostomy tube and a feeding tube," Amadeo said Monday, adding that the university did not respond to emails he sent Monday about the other hospitals' offers.

Dr. Paul R. Byrne, a clinical professor of pediatrics at the University of Toledo College of Medicine who reviewed the boy's charts, concluded that Bobby is not brain dead.

In his opinion, Byrne noted that the teen's temperature is normal, his "lungs, respiration and beating heart are functioning," and he's receiving medications that can suppress brain activity. 

"With proper medical treatment Bobby Reyes is likely to continue to live and may find limited to full recovery of brain function and may possibly regain consciousness," the doctor concluded.

In its filing, the hospital's lawyer said C.S. Mott Children's Hospital has approached other hospitals about taking Reyes without success.  

 

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Michigan wants to save $40 million by cutting PBMs out of Medicaid

October 08, 2019 04:27 PM - MICHAEL BRADY

 

Michigan's Medicaid program would like to stop using pharmacy benefit managers to oversee prescription drug claims and negotiate prices with drugmakers, according to a notice from the Michigan Department of Health and Human Services.

The state proposed that it would start managing drug coverage on its own beginning Dec. 21. Michigan hopes the move will save Medicaid money by increasing its portion of drug rebates and slashing administrative costs. The department expects the proposal will save the state about $40 million.

The state also thinks the move will streamline the administrative process for providers and ensure uniform drug coverage for Medicaid enrollees.

As drug costs continue to skyrocket, several states have stopped outsourcing prescription drug claims and negotiations to PBMs because they have failed to deliver the cost savings they promised. Recent studies have found that PBM prices often exceed Medicaid fee-for-service drug prices, which has prompted states to break off their relationships with the PBMs.

Instead of easing drug benefit administration and negotiating better prices, many state Medicaid programs think PBMs are unnecessary middlemen that use tactics like spread pricing to grow their profits without delivering real benefits to taxpayers or beneficiaries.

But PBMs say this view is misguided and that they're experienced negotiators who help states control drug costs by negotiating payment rates with drugmakers using formularies and utilization management tools that states can't develop or leverage on their own.

Drugmakers pay PBMs rebates after the point of sale and can add up to 40% or more of a drug's list price. PBMs usually try to address high drug prices by negotiating bigger rebates from pharmaceutical manufacturers, especially for brand-name drugs.

Critics, including public officials and patient advocacy groups, argue that PBMs have an incentive to prioritize high-priced drugs over more cost-effective medications because they're partially reimbursed based on the size of the rebates they get from the manufacturers. There have been a number of reports of PBMs using tiering or other strategies to favor on-patent drugs over less expensive drugs that are just as beneficial, which could cost governments and patients more money.

PBMs are facing increasing scrutiny from lawmakers as they take aim at prescription drug prices. Some PBMs have responded by merging with other healthcare organizations, which can obscure the accounting of their PBM practices inside a larger company.

 

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