Insurance

Homecare Switching Heats Up

Laurie Kelley December 16, 2007

So what is going on out there? I have gotten more emails this past week about home care switching than ever.

Tom wrote in to ask if all Anthem Blue Cross patients with hemophilia will be required to use Precision Rx as their factor provider? He is livid, if this is true. Another mom wrote in to report that she is hearing that Anthem in Ohio is forcing a switch in home care companies. She heard that Anthem’s doses may be +2%, not the current industry of dose +10%. She is concerned that this means fiddling around with the vial sizes and number of vials we get.

Still another mom, employed by a home care company herself (so she buys factor from her employer) is being forced to switch to another home care company–a competitor!– that she doesn’t like and has not heard good things about. She is very concerned. I would be too: if my son is a source of revenue for my employer and then no longer supplies revenues, will my job be on the line? A lot of parents and patients are employed in the homecare industry.

I had a long conversation with Bob Robinson, the executive director of the Illinois chapter, and he tells me now that Blue Cross Blue Shield is doing the same thing in their state. This trend is gaining speed, and this will be happening more and more. Bob and I talked about how our community is going to have to start accepting that some change is inevitable and that we are going to have to learn to compromise. There is just no way we can have “our way” any more. Most disturbing is that the insurance companies are setting up their own in-house specialty pharmacies. So they are paying for factor and getting the profits at the same time. Can they can charge whatever they want? Who is monitoring this practice?

It seems shocking, but you know, this at first seemed like much more of a market correction than an out-of-the-blue change. Health costs have risen astronomically, so payers are naturally going to do something to lower costs, as long as this does not put the patients in danger. This is what managed care is all about, and it is here to stay, whether we like it or not. Best we can do immediately is to document everything, carefully, every call, every EOB, every charge. We do pay good money, but the payers can simply say “Then go find another plan.” Harsh reality but it is the reality.

But the scary part is this: it’s not just about lowering health care costs, but control. Insurers are definitely wrestling control of our health care management. Competition is dwindling. When insurers have their own in-house specialty pharmacy (to allegedly control costs) and see the profits rolling in, who will authorize cost control then? They will be fixing the reimbursement price, and reimbursing themselves. Conflict of interest? Big time. The questions become: what is competition, how is it defined and what is fair?

I’ve been predicting this trend for three years now, since the November issue of PEN in 2004. If you’ve been reading our work this should not be such a surprise. Only the speed at which it is happening is quickening. Keep those letters and emails coming to us; let us know your insurance and home care switching story so we can pass it along to NHF, HFA… we are all working to preserve care and control, at fair cost.

Insurance Check Up Time

Laurie Kelley December 10, 2007

The return trip from Africa required some 30+ hours in transit, and flying coach on these long trips sometimes leaves me with a very stiff back. Yoga helps, but so does a visit to one of my favorite people, my chiropractor. However, I just received notice from my insurance company that it is only covering 12 visits. Any more and I need referrals, certifications, x-rays, passport, a note from my mother and proof of my existence.

Okay, so I’m kidding–just a little. But seriously, in keeping with the current health expenditure cutting trends by the insurance companies, things are changing rapidly. If I am not careful, do not read the fine print, and keep track of my visits, I could end up with a whopper of a medical bill. This happened to someone I know who also went to her chiropractor, whose office was less than forthcoming about what was and was not covered under her insurance. $1,000 is a lot to be hit with during the holidays.

The end of the year is a good time to review all your insurance policies. Call your insurance company and double-check on any changes for the New Year. You could have changes in co-pays, coverage, and deductibles. Call your human resource department at your place of employment and also check to see what has changed. We are also getting notices from Kevin’s employer about such changes for 2008. Try to stay one step ahead, so you don’t get left behind!

If you need any insurance help or have any questions, call the new toll free Bleeding Disorders Insurance Hotline — 800-520-6154, sponsored by Baxter BioScience. This innovative service is just what we need in these changing times.

Great Book I am Reading: Into Africa: The Epic Adventures of Stanley and Livingstone, by the exceptional writer Martin Dugard. This book tells the true story of the last amazing African exploration of Dr. David Livingstone in the mid-nineteenth century, and is one of my all-time favorites. Livingstone was a Scotsman, physician and missionary, and considered the greatest explorer of his time. Following the upheaval and accusations between fellow British explorers Richard Burton and John Hanning Speake, Livingstone decides to take his last voyage to Africa at the age of 53 to find the true source of the Nile. He encounters hardships and disease, and at his advanced age, is unable to return. He awaits his fate at an African village. Enter Henry Morton Stanley, a shrewd journalist upstart who is out to make a name for himself. As brash and arrogant as Livingstone is humble and tolerant, he sets out to rescue Livingstone and earn world fame. Of course, you know the outcome when they meet: “Dr. Livingstone, I presume?” is one of the world’s most famous questions. But the outcome is far from certain. Read this book for adventure, history and an insight into the minds of two amazing but very different men. Dugard has researched his subjects thoroughly, and most interesting are the descriptions of what these men endured, and how differently they perceive Africans and their respective missions. Four stars!

SCHIP Restrictions, Record Number of Americans Uninsured

Laurie Kelley September 17, 2007

NHF has sent an important email appeal to all its constituents, which includes anyone with a child with a chronic disorder like hemophilia. In a nutshell, the Bush Administration is trying to prohibit an expansion of the SCHIP, which it feels would encourage families to abandon private insurance in favor of state/federal funded insurance. NHF disagrees with this assessment and is asking constituents to consider emailing the White House directly to oppose a veto. Here’s the gist of NHF’s email:

“Bush Administration Blocks Expanded Healthcare Coverage for Children: Take Action Now
Prior to going into month-long recesses, both the House and Senate approved bills reauthorizing the State Children’s Health Insurance Program (SCHIP), and allowing more states to expand eligibility for the program to more children in families above the federal poverty level.  However, the Bush Administration, through the federal Center for Medicaid and State Operations, has instituted new policies that would severely restrict the ability of states to expand the SCHIP program, covering more children. In addition, these new restrictions may threaten the existing coverage that children in many states are already receiving. NHF has drafted a sample letter to President Bush expressing disagreement with this action and asking him to rescind it. You can help make a difference by personalizing the letter below with your own story and sending it to President Bush today.

Click here to view and personalize the letter, and send it to President Bush now.”
http://gomembers-ecommunicator.com/campaign/ProtectSCHIP

When I read this, I found this to be the most disturbing part of the news (taken from NHF’s website): “Ironically, the Congressional Budget Office reported that President Bush’s budget did not include enough funding for the SCHIP program to cover the children who are enrolled now. Therefore, it will not be able to cover those who are eligible but not yet enrolled, and/or those who might be eligible under an expanded program.” Ouch; I know personally a lot of families with hemophilia out there truly struggling.

But I encourage readers to investigate what’s up behind the headlines. For instance, I just read in the news wires today that 2 million more Americans are going without health insurance to bring the total to 47 million Americans without health insurance (making it seem even more perilous). Along with the news about SCHIP, this seems outrageous. But after digging a little, I read that these numbers may be misleading. The 47 million also includes illegal aliens and the temporarily unemployed. And yet, if you think about it, the current housing crisis will no doubt affect the wealth and employment of many, leaving more Americans than ever dependent on the government for health coverage. So, it’s not a great time to cut health care budgets, even though we’ve been saying to prepare for this for some time.

But don’t just jump on the bandwagon and fire off a message to the White House without doing your homework. Read the text of the issue, and know what the argument is about. See if you agree with it. NHF has put an explanation of what the issue is on its web site and you can check through the internet. (www.hemophilia.org) And if you are a family facing insurance difficulties, please call NHF (800-42-HANDI), or even call us and we can help direct you to someone who can help.

Why You Need to Know PBMs

Laurie Kelley October 8, 2006


This weekend I visited Cuyahoga, Ohio, near Cleveland, to speak at the Northern Ohio Hemophilia Foundation’s annual meeting. I am very grateful to Lynn Capretto, executive director, for inviting me. I was able to meet with about a dozen new families I had never met before. The weather was great, the turnout wonderful. Lynn and her team worked hard to make this a success.

My talk was on insurance (what else?) and it appeared much of the information I shared was new to these families, who listened with great attention. I was happy to know that all the families subscribed to the NOHF’s newsletter, as it’s very important that everyone these days get their local newsletter. Insurance is different from state to state and your local hemo org is the best place to get information about changes. But I was amazed that almost none of the families get HemAware, the NHF’s magazine. I urged them to sign up Monday, and of course, Monday is a holiday. Okay, make it Tuesday. If you are reading this and you don’t get HemAware, please sign up! Call 1-800-42-HANDI and get on the mailing list.

Well, the audience redeemed itself. Everyone knew what PBMs were and that’s good news. What I didn’t know, and wish I had, was that certain factor brands in Ohio are being considered for a PDL. Scary stuff! Don’t know what PDL is? For shame. Order our newsletter PEN and find out. You NEED to know!

We had a lot of laughs when I had to select the raffle winners (I say have to: Lynn volunteered me because if someone was upset that they didn’t win, they could blame me but so what? I’d be on the plane headed for Boston!). The winners? The delightful family who had been sitting right next to me all throughout the day: Chris and Renee LaBelle. Sharp, proactive and articulate. I couldn’t think of a better family to win a free trip to NHF this week in Philadelphia!

Well, I had another celebrity citing at the airport in Cleveland. I travel a lot, and now and then I bump into an odd assortment of celebrities. In the past this has included Richard Simmons, Paul Newman, Ben Affleck, Tony Robbins, Bo Diddley, and Jim Rice and Pedro Martinez (both formerly of the Red Sox). This time it was Erik Estrada. Remember him? The hunky cop in the 1980s show CHiPs? I was walking right behind him for a long while, not realizing who he was but noticing him nonetheless (celebrities somehow carry themselves differently!) and a woman cried out “It’s Erik Estrada!” I didn’t grab a photo as I am wont to do, to add to my “Wall of Fame” at home, but I do have a photo of me with Dan Holibaugh, a long-time friend, fellow parent and current employee of Matrix. Thanks to Matrix and Baxter for co-sponsoring my visit to Ohio, and to NOHF for a wonderful event.

Tune in this week to NHF in Philadelphia! I hope to have some spare time to blog!

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