Friday, November 27, 2009

Dr Medicaid, when is your next appointment?

So I have a patient with Diabetes which has recently become poorly controlled. She was on Glyburide / Metformin 2.5/500 BID and her blood glucose was in the mid 300s. HgA1C was almost 9. She tells me how she is drinking 6 or so sodas daily and not eating right. I advise her on healthier eating habits and have her double her pills for the next few weeks (2 in the am and 2 in the pm - I don't like for my patients to waste pills every time a dose is changed). She comes back for follow up a few weeks later. I review how she is eating and taking her meds and she has been doing as advised for the most part, however, her accucheck was 400. So I write a script for the higher dose of Glyb/Met (so she no longer has to double her previous script) and give her samples of and write a script for Januvia - another diabetic med.

No sooner is she out the door that we get a call from the pharmacist - her insurance requires prior authorization before filling the Januvia. Basically meaning I have to get permission from the insurance company before I can treat the patient with this med. So my nurse calls Medicaid and answers their 'screening questions' only to be told that they will not cover that until she has been on the glyb/met 5/1000 BID x 3 months. I am livid! They don't even include the past few weeks of her doubling her pills because it didn't show up in their system since it wasn't an official script.

So now she has to run around with blood sugars in the 300-400s for 3 months before they will pay for her med! And if she has to go in the hospital with DKA or hyperosmolar nonketotic diabetic coma, her insurance will have to pay way more for that hospitalization!

I wonder if I can set her up with an appointment for Dr. Medicaid's clinic since they can so easily dictate patient care. What is the point of having doctors if we cannot even treat the patient without permission?


ADB said...

I'm not in the States, but this plainly underlines the way the US healthcare system fails those it is supposed to serve. Why anyone wants to stop the current healthcare reform is beyond me.

Unknown said...

Moma, I worked in hospitals, in the adminstrative area, for over 25 years. I started when Medicare starte. We thought that was going to be a disaster. When DRG's came along I was convinced that was going to be complete downfall of healthcare in the USA.
In PA our Medicade program was similiar to yours with there heavy handed approach. I recall a lot of unsuccessful appeal and bad results as from denials. Of course the reimbursement was always at a very low level and hospitals and physicians suffered and supplemented as a result.
I certainly emphasis with your patient and you. This is not how it is supposed to be.
Now we are in the brink of a new national healthcare system which I am unable to completly understand and thankfull do not really have to.
All I can do is wish and hope for the industry, including physicians and the patients.
Sorry I can't offer and advise, help or and approach.I can only hope you felt better venting your outrage here today. It does help at times doesn't it?
Take care and give us another post about your baby. I trust she is over her recent problem and that you both had a nice Thanksgiving, Bill