Your Pain, Your Rights: Dealing With Your Physician And Your Hospital

https://rsds.org/your-pain-your-rights-dealing-with-your-physician-and-your-hospital/

Although I had concentrated on legal issues relating to pain in terminal illness, I had never even heard of CRPS until I got a call from a young mother in  California with the crippling syndrome. She had gone from being an athletic, employed, confident woman to one who could not care for her two-year old,  couldn’t work, and feared her husband was getting fed up with her inabilities and constant complaints. She was stitched to life by her innate determination, her love for her daughter and not much else. The tragic aspect of her story was that she knew, from experience, that she could get significant pain relief from a combination of fentynl patches and breakthrough medication.

Her HMO balked at the cost of fentynl and suggested that she was not really hurting. A physician at the clinic told her she was drug seeking. A clinic pharmacist yelled at her when she came to pick up medications and told her not to come back for “her drugs.” It took an HMO appeal, a complaint to the state insurance commissioner, and filing a complaint in a local court to get her relief. A little over a year later, a re-evaluation started it all over again.

In advising her, I learned that chronic pain, just like end-of-life pain, could be safely treated with opioids, and that the barriers for adequate pain management were much higher for those with chronic pain than those with terminal illnesses. I also had begun to understand that living with severe chronic pain is
as bad as dying with it-and lasts longer.

Advocacy at the systemic level may eventually make multidisciplinary pain management a reality at all disease and income levels. In the meantime, many chronic pain sufferers will continue to fight it out one physician and one appointment at a time-not always successfully. As with much of medical care, self-advocacy
is absolutely necessary. You need to know your rights.

Getting Off on the Right Foot

CRPS patients with untreated pain often feel that the physicians they consult are unfeeling, paternalistic, judgmental gate-keepers. Although this image may fit some, it is more useful to see the prescriber in a different light and do your best to respond to his limitations, which may include:

• lingering doubts about whether CRPS is a real syndrome
• poor training in pain management, or training against using opioids for chronic pain because, despite reassuring words, his state medical board takes a hard line on physicians who prescribe them.
• feedback from a pharmacist that the physician is prescribing too much pain medicine
• intense pressure from your HMO to hold costs down by not prescribing the more expensive formulations
• bad experiences with other opioid patients, making him feel that chronic pain makes for needy, time-consuming and difficult patients
• the knowledge that honest physicians have unfairly been indicted for their prescribing habits.

For all these reasons, physicians are often fearful and wary of chronic pain patients and they cannot help but wonder which one will get him in trouble. The physician who simply refuses to use opioids for anything but acute pain, and then only for brief periods, is not going to help you, even though the AMA ethical standards require member physicians to provide patients with “adequate pain control, respect for patient autonomy, and good communication.1” However, he should be willing to refer you to someone who will provide effective pain care. In Florida, California and a few other states, physicians are legally required either to treat pain or refer. In other states, the obligation is usually defined in the medical board regulations. Certain specialty boards have adopted standards or guidelines on the use of opioids to treat chronic pain.

If you would like to provide your physician with state laws and guidelines regarding opioid treatment, they are available online at http://www.medsch.wisc.edu/painpolicy/matrix.htm

Prescribers who use opioids for pain management must feel secure about treating you and your pain and must overcome his comfort level limitation on dosage. Therefore, put aside your anger and frustration to present yourself as effectively as possible. Let the physician know that you are responsible and willing to cooperate to protect you both. Bring all the records you have to the first visit and let him know if opioids have helped you in the past. Be aware, however, that physicians are conditioned to see this as demanding a particular opioid; be clear that you are only informing.

Good physicians will have some practice management tools in place, so don’t take it personally if you are asked to sign a pain “contract” and to submit to blood or
urine monitoring. Contracts are actually a form of detailed and interactive informed consent. Good physicians will regard some contract violations as reason to evaluate and discuss what certain actions mean and will understand that actions that look like abuse can also be clear signals of under-treated pain, dysfunctional living arrangements, or manifestations of depression or anxiety.

Let the physician know if you need to “violate” one of the contract rules-such as requesting early refills so that you can go out of town or increase the dose in a time of particularly serious pain. However, you still have pain, call the physician before you increase the dose and ask for an appointment to talk about titration. If you can’t afford an interim visit, try to speak with him by telephone to explain how you are feeling, or have a friend or relative call him to express concerns.

Finally, do not be shocked or offended if he asks you to have a psychiatric consultation. This need not mean that he thinks your pain is “all in your head”. Depression and anxiety are almost synonymous with chronic pain, as is social isolation. Many studies show that a psychological evaluation and even ongoing psychological care can substantially improve pain management, as can other modalities, such as neurocognitive feedback. And, of course, it gives your physician some “cover” to have another professional involved. If money is an issue, let him know.

It is a good idea to bring a relative or friend who will talk to your physician about your suffering and the functional difference that pain medicine makes because prescribers are reassured when a patient using opioids has a visible support structure. It is also less likely that the physician will be rude or patronizing in front of a supportive friend or relative.

Some pain management physicians who are anesthesiologists by training have a firm bias toward invasive procedures over medical management, so they may suggest that you repeat sympathetic blocks or expensive tests even if a previous physician has already tried them. You have no obligation to go along, particularly
if your records reflect a history of procedures. The physician is obliged to seek your informed consent, which requires a discussion of risks and alternatives. Although you do not have to give it, the unfortunate upshot may be that he declines to treat you further.

You and Your Physician: What are Your Rights?

Reality dictates that some physicians, even in the face of clear pain, will not be willing to prescribe opioids. More commonly, they are willing to prescribe low doses but have a personal comfort level limit that may or may not be adequate for you. Moreover, if you push him to titrate doses above that comfort level, he may decide that you are a drug seeker. This serious ethical problem-the physician putting his perceived personal safety before his patient-is a deplorable situation
that can lead to abandonment.

A physician can abandon a patient whom he views as drug seeking or who has in some way “violated” the informed consent agreement. Although state laws and medical ethical rules do not allow abrupt termination of a physician-patient relationship, a prescriber does not have to keep you in his practice. If you are stable and able to find another physician, he can terminate you if he provides a brief written explanation of his reasons. An oral message is insufficient. The physician
must also agree to continue your care for at least 30 days and he should also provide a referral.

However, if you are at a critical or important point in your treatment, abandonment by notice and 30-day care is not permissible under common law. This restriction should apply to a patient taking opioids for pain because the consequences of withdrawal for a person who has a chronic illness could be significant.
Additionally an un-medicated patient may face a return of the pain that had been mediated by the opioids; he will almost certainly experience anxiety and distress. In short, a period without continuity of care could constitute a medical emergency. It seems logical that refusal to treat a patient until the patient has obtained another physician (or perhaps until it becomes clear that the patient is not making a serious effort to transfer care) should constitute abandonment.

What Can You Do?

Try Informal resolution. Deal with the termination immediately. If the physician is in a clinic setting, ask the head of the clinic if another physician there will take over your care. Speak to other health care professionals who know you well enough to be comfortable calling to explain that you are genuinely in pain and are a reliable, conscientious person.

Ask for a meaningful referral. Tell your prescriber you will need his help in finding another physician and you have a right to his assistance.  Get your records and review them carefully. Federal privacy law (HIPAA) requires your physician to provide your records promptly and to charge you no more than his actual costs of copying. It also allows you to have your records corrected if they contain errors. Review them for accuracy and look closely at what they say about the reason for termination. Phrases like “drug seeking” or “possibility of abuse” will hurt your efforts to find another physician. If he has used these phrases, write him a letter, preferably through an attorney, and use the words “abandonment,” defamation” and “emotional distress” if the attorney confirms that they are appropriately used in your state.

File a Complaint with the State Medical Board. Every state has a medical board that reviews all complaints and takes action when necessary. Only two state boards have disciplined any prescriber for under treating pain, so it is not possible to see this yet as a meaningful remedy. However, as more complaints are made and individual physicians show a pattern of patient abandonment, state boards are more likely to act.

State board complaints are not complicated. You do not need an attorney, but if you have one, take advantage of his advice. The forms themselves are simple and straightforward and are available on your state’s website. You can also order them by phone. Make your complaint more effective by writing a clear statement of what happened to you and any difficulties that you are having in finding another physician. Avoid a long, rambling statement. It may help if you number each paragraph and tell your story chronologically. If possible, have someone else read it to make sure it seems clear.

Do not feel limited by a form that does not allow much space for your comments.

Explain the emotional and physical impact of the termination. If you think your physician terminated you unfairly, state why. Make it clear if he was verbally abusive! Attach brief statements by anyone who has observed the impact that the termination has had on you and any other documents that may help the board understand that you are a legitimate pain patient with a serious medical condition.

If you want to follow up with the board, talk with the clerk to make sure it was put on the docket. Find out who is responsible for the investigation and ask to speak with him. Answer any questions and ask to be kept informed of case progress.

Consult an Attorney About a Formal Action

Abandonment is a tort (legal wrong) that may give you cause for a legal action against your physician. To prove abandonment you usually have to show (a) a physician-patient relationship; (b) that was terminated or neglected by the physician and (c) that caused you harm. An attorney can advise you about
your state’s requirements. Additionally, there is a tort called “infliction of severe emotional distress,” which requires (a) an action taken by the defendant (b) which was reasonably foreseeable to cause severe distress; and (c) that it did in fact cause severe emotional distress. Some states require a physical injury, but there is some precedent that recognizes pain as such. A growing body of medical evidence that untreated pain has serious physical consequences would
substantiate this view. If the defendant physician knew and intended to cause the emotional harm, a more serious tort is invoked. The requirements of these torts are often complicated and you should discuss your state’s precedents with your attorney.

Do not take a suit lightly and do not expect a windfall. Litigation is very hard on anyone with a chronic illness and even more so with RSD because of the stress involved. It prevents you from moving on. If you cannot afford to pay an attorney, you will have to convince one that the case is worth taking on a contingency basis; experience has proven this difficult. Most attorneys know very little about opioids and even less about pain management. You will need to educate your attorney so that he can evaluate your case intelligently.

You can find additional information on legal assistance in the directory, In Pain and Agonizing Over the Bills. For a print
copy, contact the RSDSA office at (877) 662-7737.

1. AMA Ethical Statement 2.1, made effective for chronic
pain by the Council on Ethical and Judicial Affairs in 2002.

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I am not sure what this really means, but if the PBM has anything that resembles a “free hand” in setting up out-of-pocket costs for Medicare Part D programs, it will be the pt that gets financially screwed and the PBM industry will prosper financially.  Barb has been Part D prgm since they started in 2006 and has a ZERO DEDUCTIBLE from the beginning.  Over the last few years, ours and most Part D prgms have implemented $500+/yr deductibles and the annual deductible now exceeds the total of the monthly premiums.  Over just a few years, our out-of-pocket for premiums and deductibles has OVER DOUBLED.  With next year’s out-of-pocket limited to $2,000, could we see a dramatic increase in premiums, deductibles, prescription prices and the copay tier of many meds being moved up to higher tiers?  Meaning that the PBM industry will be generating more profits from pts because the spread pricing between a lower tier and upper tier will go directly to the PBM’s bottom line. I just checked what our out-of-pocket for Rx copays and deductibles was for 2021 & 2022 was < $1000 each.  It would probably be pretty easy for our Part D to raise our deductibles and tier level on all our Rxs to push our out-of-pocket an extra $500/yr for each of us… all that would drop to the PBM’s bottom line.

NCPA advocates for pharmacy in calls with CMS, HHS, White House

https://ncpa.org/newsroom/qam/2023/05/26/ncpa-advocates-pharmacy-calls-cms-hhs-white-house

Starting in 2025, Part D patients can elect to have cost-sharing “smoothed” out over the course of the benefit year under the Inflation Reduction Act and can elect to pay their cost-sharing in monthly installments. Out-of-pocket costs for Medicare Part D beneficiaries will be capped at $2,000 per year in plan year 2025. In subsequent years, the $2,000 threshold will be increased at the rate of growth for the Part D program. On May 24, NCPA’s Steve Postal attended an IRA workshop hosted by the Centers for Medicare & Medicaid Services and its contractor, Mathematica, and focused his comments on potential plan behavior that may add administrative burden to pharmacies. He also warned CMS to be wary of plan and PBM efforts to use education on smoothing to steer patients to PBM-affiliated pharmacies The following day, on May 25, NCPA’s Steve Postal and Anne Cassity spoke with the Department of Health and Human Services and White House officials about the IRA and the need for standardized educational materials published by HHS that alert patients to the copayment smoothing provision. They reiterated NCPA concerns that such educational efforts would add administrative burdens to pharmacists. Postal also asked HHS officials to report on the status of the HHS Bridge program that would provide COVID-19 vaccines from pharmacists to uninsured patients. HHS responded that it will be following up with more information on the copayment smoothing provision, as well as the HHS Bridge program.

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Filed under: General Problems | 6 Comments »

There is many things starting to STACK UP against the DEA/DOJ and their 5 decade war on drugs/pts. There is more and more practitioners – especially pharmacists – that are work with pharmacogenomics  https://www.pharmaciststeve.com/21st-century-testing-to-help-chronic-pain-pts-justify-needing-higher-doses/ to help determine if a pt metabolizes different categories of medications differently.  Pointing out that some pts are fast/ultrafast metabolizers of many meds are dealing with pts suffering from subjective diseases (pain, anxiety, depression, ADD/ADHD, various mental health issues) where historically there have been lab/test issues that have been ignored or dismissed they were involved in adversely affecting a pt’s QOL… 

That the MME system has no science nor double blind clinical studies supporting their conclusions are nothing more than JUNK SCIENCE, but “they” have continued to use them as a ONE SIZE FITS ALL in the treatment of subjective diseases.  https://www.acsh.org/news/2022/03/01/true-story-morphine-milligram-equivalents-mme-16154

“They” continue to blame Purdue Pharma was the genesis of the fabricate opioid crisis  – yet it has been claimed that Purdue Pharma’s opioids were only 4% of all opioid Rxs.

“They” ignore that over the last decade, legal opioid Rxs have been reduced abt 50%, while concurrently the number of Opioid OD/poisoning have increased 7-8 fold, but only mention that those deaths were from Fentanyl – mostly failing to mention that the Fentanyl analog involved – that is mostly coming from China and Mexican cartels – is not the same FDA approved Fentanyl analog.

Now the 50 state AG’s sued the top 3 drug wholesalers and three largest chain pharmacies and besides getting these corporations to “cough up” tens of billions of dollars in fines for “contributing’ to the fabricated opioid crisis and at the same times getting these corporations agree to sell fewer control meds to pharmacies and chain pharmacies agreeing to dispense fewer controlled meds.  Apparently doing so, in little regards for the pts valid medical needs for these medications.  https://www.pharmaciststeve.com/dea-surrogates-are-trying-to-throttle-the-availability-of-controlled-meds-to-pts/

       Practitioners have been reducing or eliminating a pt’s pain medication and ignoring some predictable comorbidity complications, especially  hypertensive blood pressure,  heart attacks,  strokes,  increase pain,  anxiety & depression & suicidal idealization. 

Chronic Pain Detected in the Brain for the First Time

Real-world signals were seen mostly in the orbitofrontal cortex

https://www.medpagetoday.com/neurology/painmanagement/104635

Chronic pain was detected in the human brain for the first time, researchers reported.

Data were collected over months from four participants with refractory neuropathic pain who had intracranial electrodes implanted, according to Prasad Shirvalkar, MD, PhD, of the University of California San Francisco, and co-authors. Over 3 to 6 months, participants reported their pain levels several times a day at home while the electrodes recorded their brain activity.

The recordings showed that chronic pain states were mostly associated with activity changes in the orbitofrontal cortex, Shirvalkar and colleagues wrote in Nature Neuroscienceopens in a new tab or window. This differed from transient or acute pain, which was associated with anterior cingulate cortex signals in two participants.

Functional MRIs have shown that the anterior cingulate cortex and orbitofrontal cortex regions are activated during acute pain experiments, Shirvalkar noted.

“We were interested to see whether these regions also played a role in how the brain processes chronic pain,” he said in a press briefing. “We were most interested in questions like how pain changes over time, and what brain signals might correspond to or predict high levels of chronic pain.”

Pain is one of the most fundamental experiences an organism can have, Shirvalkar observed. “Despite this, there is still so much we don’t understand about how pain works,” he pointed out. “By developing better tools to study and potentially affect pain responses in the brain, we hope to provide options to people living with chronic pain conditions.”

Chronic pain has no objective biomarkers to help guide diagnosis and treatment, Shirvalkar added.

In the U.S., the prevalence of chronic painis about 21%, affecting an estimated 51.6 million adults. New cases of chronic pain occur more frequently than new cases of diabetes, depression, or hypertension.

This study, which was supported by the NIH’s BRAINand HEAL initiatives, may be a first step toward developing novel methods for tracking and treating chronic pain, noted Walter Koroshetz, MD, director of the National Institute of Neurological Disorders and Stroke. “We are hopeful that building from these preliminary findings could lead to effective, non-addictive pain treatments,” Koroshetz said.

Shirvalkar and colleagues surgically implanted electrodes that targeted the anterior cingulate cortex and orbitofrontal cortex of four participants. Three participants had post-stroke pain and one had phantom limb pain.

Participants were asked to evaluate the pain they were experiencing — strength, type of pain, and how the pain made them feel — several times a day. They then clicked a remote-control device to create a 30-second brain recording of that moment.

Using machine learning methods, the researchers successfully predicted the pain severity scores of each individual from their orbitofrontal cortex activity with high sensitivity. Each person showed unique brain activity.

“Each patient’s biomarker was actually like a unique fingerprint,” Shirvalkar said. “I think that tells us something very important.”

In a separate analysis, Shirvalkar and colleagues examined how the anterior cingulate cortex and orbitofrontal cortex responded to acute thermal pain. In two participants, activity in the anterior cingulate cortex predicted acute pain responses.

The findings suggest that signals in the orbitofrontal cortex can track current chronic pain severity for neuropathic pain syndromes such as central post-stroke pain or phantom limb pain, the researchers said. The data also suggest that the brain may process chronic and acute pain differently in chronic pain patients.

“Global cerebral pain networks in all participants likely underwent rewiring over many years living with chronic pain,” Shirvalkar and co-authors wrote. “Still, ongoing ‘background’ chronic pain may have influenced acute pain perception even in the unaffected body side,” they noted.

Future work involving more participants may help determine whether different pain conditions share the orbitofrontal cortex activity found in these participants or how signatures may vary among persons with different pain conditions, the researchers added. Whether similar signals could be recorded non-invasively with electroencephalography (EEG) is not known.

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I got the text below today as a email. How many of those in the chronic pain community have reached out to the ACLU for assistance in because of their disabilities being discriminated against and all have been told that ” we don’t have the resources” … According to this text, … Here’s your rundown,  and we’ll be back with more news tomorrow on the slew of lawsuits we’ve hustled to file once our attorneys have had a moment to breathe.  One would think that the estimated 50 million of adults and USA citizens dealing with chronic pain would fall into ACLU’s Over the past two weeks, our attorneys have been filing lawsuit after lawsuit to fight against the surge of attacks on people’s most fundamental rights & BEYOND.  As Cardinal drug wholesaler is notifying independent pharmacists that – effective immediately, they are no longer going to sell them controlled meds and Walgreens are sending pts a 23 point questionnaire for their prescriber to fill out – mostly with a narrative answer – if Walgreens will continue to fill the prescriptions of a particular prescriber going forward. Here is a recent blog post laying out what may be coming down the pike for those in the chronic pain community

DEA & surrogates are trying to throttle the availability of controlled meds to pts

Over the past two weeks, our attorneys have been filing lawsuit after lawsuit to fight against the surge of attacks on people’s most fundamental rights: From the rights and safety of trans people to voting rights to abortion access and beyond.

We will be back with further updates on these urgent fights in the courts soon, but we wanted to uplift one particular breaking lawsuit that our legal teams just filed this week in the state of Florida against yet another harmful ban from Governor DeSantis.

Here’s your rundown,  and we’ll be back with more news tomorrow on the slew of lawsuits we’ve hustled to file once our attorneys have had a moment to breathe.

The Ban: Florida Governor Ron DeSantis very recently signed into law SB 264. This racist law forbids many immigrants from China, Cuba, Venezuela, Syria, Iran, Russia, and North Korea from buying a home in the state – with very limited exceptions. The law singles out people from China for especially draconian restrictions and harsher criminal penalties. Gov. DeSantis has said that this bill is “necessary to combat the influence of the Chinese Communist Policy in Florida,” but he is wrongly equating Chinese people with the Chinese government. This law will not keep Floridians safe. It will upend people’s lives and make it far more challenging for immigrants to prosper economically in the state.

Our fight back in court: The ACLU, ACLU of Florida, Asian American Legal Defense and Education Fund, and DeHeng Law Offices PC are working together to challenge the Florida law before it goes into effect on Saturday, July 1. The plaintiffs in our case include Chinese citizens who live, work, study, and raise families in Florida, and who will soon be prohibited from purchasing real estate.

Why this is so important nationally: Worryingly, Florida isn’t alone. Lawmakers across the country are trying to pass laws to ban Chinese citizens and other immigrants from owning property. Just as states have continued to bring out anti-trans, anti-abortion, and anti-voter legislation in droves this year – despite citizens and public opinion clearly stating the opposite – so too are we seeing similar anti-immigrant and xenophobic bills like this one take shape.

The bottom line,  is this: At a time when one in two Asian Americans report feeling unsafe in the U.S. due to their ethnicity – and nearly 80% don’t feel they fully belong or are accepted – Florida’s leaders have a responsibility to the people who live there to do better.

Until they do, we’ll see them in court.

More from our attorneys soon,

The ACLU Team

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Maybe this is why they are starting to refer to this as Medicare-C – because there is no advantages

Congress Hearing Explores Medicare Advantage Routines That Deny, Delay Needed Care

https://www.medpagetoday.com/publichealthpolicy/medicare/104569

WASHINGTON — A 79-year-old man with prostate cancer needed a PET scan, but his Medicare Advantage (MA) plan refused to pay for it. Another MA plan denied approval for a wheelchair for a patient with multiple sclerosis and a tibia fracture. Still another enrollee recovering from a stroke found he was ineligible for coverage for physical therapy.

The neurosurgeon treating a fourth patient, the late University of Connecticut physics professor and melanoma patient Gary Bent, PhD, referred him for acute rehab after removing a lesion from his brain. But Bent’s MA plan intermediary refused, putting him and his wife, Gloria, through a lengthy ordeal They were told he “couldn’t withstand intense therapy,” she said.

He was eventually admitted to a skilled nursing facility, but was discharged from there after about 5 weeks because his MA plan discontinued payment, even though it turned out he had bacterial meningitis, she said.

Those were among many examples of how MA plans have routinely denied coverage for medical services — despite their doctors’ orders and despite Medicare policy that they should be covered — presented Wednesday during a hearing of the Senate Homeland Security and Governmental Affairs Permanent Subcommittee on Investigations.

Lawmakers have collected many examples in which MA plans are failing beneficiaries, “denying or delaying care,” said committee chair Sen. Richard Blumenthal (D-Conn.) at the start of the hearing. They “face denials in the middle of major medical crises, forcing them and their loved ones to fight even as they are fighting for their lives.”

Algorithms Decide

“Perhaps most troubling of all,” Blumenthal continued, “there is growing evidence that insurance companies are relying on algorithms rather than doctors or other clinicians to make decisions to deny patient care.”

Sen. Roger Marshall, MD (R-Kan.), an ob/gyn, listed many examples of denials, including the examples above.

He said a huge culprit is prior authorization, in which MA companies — to avoid waste and reduce costs — require doctors to get many kinds of medical care pre-approved. A few years ago, an MA plan canceled Marshall’s patient’s next-day surgery because Marshall was required to talk with a plan representative first. Prior authorization has “become a tool to delay care — hoping the patient dies so they don’t have to give any more care, I guess.”

One focus during the hearing was on the MA plans’ frequency of incorrectly denying care. Of 35 million prior authorization requests submitted to MA plans in 2021, 6% or two million were denied, said Jean Fuglesten Biniek, PhD, associate director of Medicare policy for the Kaiser Family Foundation here. Of those, only 11% were appealed and when they were, 80% of the denials were overturned, suggesting that many denials should have been initially approved.

These denials burden providers’ staff resources and impose delays for enrollees “during a point in their lives when they’re potentially in very poor health,” she said.

Why such a low rate of appeals? Biniek was asked. “People may not know how to appeal; they may not believe they have a case to appeal. And people are often very ill … and if they don’t have a caregiver or somebody to assist them or access to legal services, going through that process can be difficult,” she replied.

A key problem with MA plans is their refusal to pay for skilled nursing facility stays or approve coverage for lengths of stays that doctors say their patients need, said Christine Huberty, an attorney with the Greater Wisconsin Agency on Aging Resources, which provides free legal services for seniors.

For a patient who has undergone hip replacement surgery in a hospital, for example, she said, “their doctor generally recommends several weeks in a skilled nursing facility until they’re ready to safely go home.”

In regular Medicare, that patient would be covered for up to 100 days of skilled nursing facility care after a 3-day hospitalization. But although MA plans are supposed to provide the same coverage, Huberty said, too often they don’t.

Dizzying Red Tape

Instead, a senior “can expect to receive a denial well before their doctor even says they’re ready to go home … they’re thrown into a maze of red tape that is dizzying, even to our experienced legal team,” fighting a denial that is made by “a third-party contractor using an algorithm,” Huberty said.

The length of that patient’s stay is determined by a computer based on millions of “past beneficiary data points, not the patient’s plan of care or the advice of their doctors,” she continued. If the patient chooses to fight, denials at each level are upheld by a quality improvement organization, often with little to no explanation, she said.

Megan Tinker, chief of staff of the Office of Inspector General (OIG) for the Department of Health and Human Services (HHS), noted that Medicare pays MA plans a capitated rate per beneficiary, and thus have “a potential incentive” to deny access to services they should cover.

For example, she said, a plan denied payment for a computed tomography scan, medically necessary to rule out a life-threatening aneurysm, referencing a rule that beneficiaries are supposed to first get a less-expensive x-ray. “But Medicare has no such requirement,” Tinker said.

Prior authorization is being used to deny care that, in 13% of the cases investigated, traditional Medicare would have paid, Tinker told lawmakers. “Plans make more money by providing fewer services.”

Although OIG has reported on this problem, its oversight abilities are limited by resources. The agency receives 2¢ to oversee every $100 HHS spends, and each year turns down between 300 and 400 “viable criminal and civil healthcare fraud cases,” leading to the “potential for patients to be put in harm’s way, including individuals enrolled in Medicare Advantage,” Tinker said.

They Didn’t Choose

It’s not as if the cost savings that MA plans were designed to achieve are happening, Biniek said. In its report, the Medicare Payment Advisory Commission projectedopens in a new tab or window that in 2023, the trust fund will pay $27 billion more for MA enrollees, or 6% more, than similar patients with traditional Medicare.

One witness at the hearing, Lisa Grabert, MPH, a visiting research professor at Marquette University’s College of Nursing in Milwaukee and a former staff member of the House Ways & Means Committee, praised MA plans, saying that both of her parents are enrolled in them.

She said beneficiaries are choosing MA plans for their comprehensive benefit packages and “improved financial protections” and “choice simplicity,” and that beneficiaries are willing to accept the trade-offopens in a new tab or window of using a provider network with some utilization review requirements such as prior authorization.

“It is our expectation that a Medicare beneficiary has a basic understanding of this when they elect their choice of coverage,” she said. “However, it may not be clear to beneficiaries what they are agreeing to when it comes to prior authorization.”

Later in the hearing, Blumenthal referenced Bent’s case, and whether he had an informed choice to buy an MA plan.

“Actually,” his widow replied, “Gary was a retired state employee whose benefits were determined by the Office of the State Comptroller … Someone else made the decision for us that we would be on Medicare Advantage.” Her husband died in March after developing an infection.

Blumenthal summarized as he adjourned the hearing: MA plans’ denials and delays of care “deeply impact people, impoverishes them financially but also spiritually when they have to be on the battlefield at the same time their loved ones are fighting for their lives,” he said.

“The fact of the matter is [an MA plan] works until you need it,” he said. “It’s fine, so long as you don’t need it for the big stuff, like melanoma, like long term care, like certain kinds of injections, and other needs that everyday Americans have.”

How Congress should fix the problem remains unclear. But, Blumenthal said, “This investigation will continue. There’s a lot here that needs to be known.”

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If you are reading this, YOU NEED TO SHARE THIS – not just LIKE IT… unless you feel that there is no one in your circle of family & friends who are dealing with chronic health issues, that could possibly benefit & enjoy improving their QOL. If you are a intractable chronic pain pt, this could give your prescriber HARD JUSTIFICATION why you need a higher dose.

For years, those who follow and read my blog… Have heard me routinely talk about pharmacogenomics (PGx). “back in the day”, I was a hard-charging, card carrying, type-A workaholic.  Now in my 8th decade on this earth, those words no longer really applies to me. I could not, in good conscience , pull back from supporting those in  the chronic pain community, to try and get up to speed with PGx. So I started looking around to find a Pharmacist that has this PGx stuff down pat. Must have been my GOOD KARMA day. I found Cari A. Lalande, PharmD, RPh
Owner | Clinical Genetic Pharmacist.

FULL DISCLOSURE: I won’t get the first penny for being a conduit in connecting Cari, with someone in the community who wants to see if PGx/NGx could help improve their overall health/QOL.  This is Cari’s professional business/practice, and she does charge for her services and will bill insurance, if it is covered. I think that it would be best, if any/all pts asked their practitioner if they will use/believe in PGx testing. There are some practitioners that are still working with 20th century knowledge and skill sets.

Last, but not least, Cari has agreed to become a contributor to my blog. Sharing stories about pts she has helped using PGx & NGx and the positive QOL outcomes she has been able to accomplished for these pts.

Health By Genetics™ is a unique pharmacist owned genetic lab designed to conduct comprehensive pharmacogenomic (PGx), nutrigenomic (NGx) molecular testing. Our wholistic approach to patient-centered care empowers individuals to live life abundantly, on their terms.

Utilizing genetics as the basis, we work with both the patient and their providers to determine the best medication choice for each thereby reducing the occurrence of side effects, polypharmacy, and increase awareness of better lifestyle choices. 

Our goal is to solve for challenges most patients face when multiple providers are involved in prescribing various

medications without communicating with each other thereby increasing the risk of adverse side effects and related events.

To continue to support our patients, because genetic testing is not a one and done type of test, we created our PharmaAssist^TM Concierge clinical services program that provides patients a personal genetically trained pharmacist to act as their patient advocate with their healthcare providers.

Click here to schedule a meeting: https://calendly.com/health-by-genetics

Click here to schedule a meeting: https://calendly.com/health-by-genetics

Nutrigenomics is a field of study that investigates the relationship between nutrition and an individual’s genes. It explores how genetic variations influence the body’s response to different nutrients and how diet can affect gene expression and function.

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Chronic Pain Incidence Is High in the U.S.

https://www.medpagetoday.com/neurology/painmanagement/104558

New cases of chronic pain — defined as pain experienced on most days or every day over 3 months — occurred more frequently than new cases of other common chronic conditions, U.S. survey data showed.

Chronic pain incidence was 52.4 cases per 1,000 person-years, reported Richard Nahin, MPH, PhD, of the NIH in Bethesda, Maryland, and co-authors.

This was higher than the incidence of diabetes (7.1 cases/1,000 person-years), depression (15.9 cases), and hypertension (45.3 cases), the researchers said in JAMA Network Openopens in a new tab or window.

Moreover, chronic pain was persistent: nearly two-thirds (61.4%) of adults with chronic pain in 2019 continued to have it in 2020.

The findings come from National Health Interview Survey (NHISopens in a new tab or window) data and are the first nationwide estimates of chronic pain incidence.

Recent NHIS data showed the prevalence of chronic painopens in a new tab or window in the U.S. was about 21%, affecting an estimated 51.6 million adults. High-impact chronic pain — pain severe enough to restrict daily activities — affected 17.1 million people.

“Understanding incidence, beyond overall prevalence, is critical to understanding how chronic pain manifests and evolves over time,” Nahin said in a statement. “These data on pain progression stress the need for increased use of multimodal, multidisciplinary interventions able to change the course of pain and improve outcomes for people.”

The NHIS is a cross-sectional poll conducted annually by the National Center for Health Statistics. Nahin and co-authors evaluated 10,415 adults who participated in both the 2019 and 2020 surveys. Participants with chronic pain during both periods were considered to have persistent chronic pain.

The sample included 51.7% women. More than half of the study population — 54% — were ages 18 to 49. Most participants (72.6%) were white; 16.5% were Hispanic and 12.2% were Black. Most (70.5%) were not college graduates.

At baseline (2019), 40.3% of participants reported no pain, 38.9% reported non-chronic pain, and 20.8% reported chronic pain.

Of those without pain in 2019, the rate of incident chronic pain was 52.4/1,000 cases (95% CI 44.9-59.9). The rate of incident high-impact chronic pain was 12.0 (95% CI 8.2-15.8). Lower educational attainment and older age were associated with higher rates of chronic pain in 2020, regardless of pain status in 2019.

In 2020, rates of persistent chronic pain and persistent high-impact chronic pain were 462.0 and 361.2 cases per 1,000 person-years, respectively.

Of those reporting non-chronic pain in 2019, 14.9% had progressed to chronic pain at follow-up. Of those reporting chronic pain in 2019, 10.4% had fully recovered (were pain-free) in 2020.

“Although chronic pain is sometimes assumed to persist indefinitely, our finding that 10.4% of adults with chronic pain experienced improvement over time is consistent with previous evidence from studies in Denmark, Norway, Sweden, and the U.K., which revealed rates ranging from 5.4% to 8.7%,” the researchers noted.

The study did not include information about the underlying causes of pain and survey data were collected only twice across 2 years of follow-up, Nahin and co-authors acknowledged. It’s possible that people experiencing new or persistent chronic pain or high-impact chronic pain were less likely to participate in the 2020 follow-up survey, which may have led to rates being underestimated.

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