I received an e-mail with my “physician folio” report and a reminder that I would have to pay my $175 annual fee. It was my understanding, or, I guess, misunderstanding, that that was optional and that I could instead choose to pay for my next recertification exam in 10 years. I e-mailed the #ABPN (http://www.abpn.com/) and was told that previously, board certification was paid for at the time one applied for an exam. As of 2012, as part of the C-MOC program, the Board decided to change to an annual fee payment structure. Instead of a single fee at the time of the MOC examination, participants in the C-MOC program pay an annual fee. This fee covers Maintenance of Board Certification status, use of a personalized ABPN Physician Folios account with customized MOC tracker, and development and administrative costs of MOC examinations, including a 10% credit annually towards an MOC examination in a ten-year period. Maintaining board certification status does require satisfying the MOC requirements as well as payment of the annual fees. I was told, “when you apply for your next MOC exam, you will be able to apply the payments of the annual fees you have paid thus far to credit towards the cost of that MOC exam.” And by the way, diplomates certified before 2012, including lifetime certificate holders, may elect to participate in the program through their physician folios account. That means that they can simply continue on as they had been doing while the rest of us are punished because we recertified or were initially certified after 2012.

I responded that I may not choose to recertify again, as I will be 63 years old by that time and possibly retired. No statement was made regarding that, so I can only assume that the board then keeps all that money anyway for those nebulous “exam development and administrative costs.” And though I paid $1400 for the exam this time, I guess that that means that buried in the annual $175 fee over 10 years is that same $1400, though it is hard to imagine a greed driven board maintaining the exam at the same price in 10 years. But I figure, with all the psychiatrists required to do this now, that $175/year adds up to a nice small treasure that I am sure will more than adequately cover exam development and administrative costs while allowing the CEO to see an increase in his already >$800,000 year salary. Since I may not recertify at that time, I certainly don’t want the board sitting with any of my money to “save” it for the exam fee. I can keep track of my own credits and don’t need an ABPN-monitored physican folio to do it for me. The last I checked, the guidelines for maintaining certification are still published for free. This seems like just more ABPN needless bureaucracy and a way to generate more income for the ABPN, as there is no value in this for the ABPN diplomates. The ABPN website notes that with these physician folios “physicians can activate accounts that will enable them to keep their demographic and license information up to date, view and attest to their MOC activities, and apply and pay for examinations and annual MOC fees. Physicians must activate an ABPN Physician Folios account on the ABPN website to begin the MOC process and gain the benefits of the program.” What benefits? You mean that this is necessary and we simply cannot enter a payment portal on our own to pay for exams? We cannot send in an annual report attesting to our MOC activities? There has to be a “physician folio” that we have to finance with our ever dwindling dollars? Those so called “benefits” of paying an annual fee feel distinctly like self-aggrandizing rationalization for what amounts to extortion. Indeed, further down the same page, ABPN again explains/rationalizes the fee in a poor attempt to anesthetize us into a sense of “just business as usual” in much the same way various other organizations pull the proverbial wool over the eyes of their constituents. Just look out how enticing these “benefits” are:

There are several advantages C-MOC program participants gain:

• Annual fee instead of a large fee at the time of application
• Customized list of MOC activities that can be provided to employers, hospitals, licensing boards, etc.
• Reminders from the ABPN regarding MOC requirements that are due to be completed
• Easy-to-use system to track individual requirements
• Personalized ABPN Physician Folios account.

I wrote again to express my concerns and was informed that indeed the MOC requirements and annual fee do need to be satisfied as long as a diplomate wishes to maintain certification. If after 3 years of not keeping up-to-date with the requirements, status will be changed to “Certified – not meeting MOC requirements.” If after 6 years one is not up-to-date with requirements, then that doctor would no longer be board certified (despite having passed the exam 6 years prior!) A diplomate may change his/her status back to “Certified – Meeting MOC requirements” upon successful completion of a block of MOC requirements and payment of all required fees.

This entire process is completely unfair. I have no problem meeting MOC requirements if I have to, though I also think that that is a farce because it does not confer upon any doctor any special status as far as clinical acumen or excellence as a physician. It solely proves that a doctor can find suitable credits to pass to satisfy the requirement. Many of us lead very busy lives, not only in practice but outside of work, and really don’t need more to do. I own and operate a completely solo practice and do all my own administrative work. I don’t need more to do. I earn the requisite number of credits each year to satisfy ABPN and state board requirements. How can the board not only justify more onerous requirements but then make us pay for the “privilege” of such upkeep? This smells like profit mongering on the part of ABPN, just like the ridiculous burden and cost of needing to recertify every 10 years for those of us who graduated after 1993. EVERYONE should need to recertify, or nobody at all. If I choose to recertify in 10 years, I would still rather pay once at that time rather than give the ABPN any of my money annually. The CEO of the ABPN is already paid over $800,000/year, so it is obvious where the money is going. I am not in business to help keep the ABPN afloat and am truly hopeful that soon enough there will be other certifying boards that become accredited. I may have one more certification in my career, but if I have another option I will gladly move away from the ABPN at that time. I would love to continue this discussion with whoever is making these decisions.

Normally, ordering a 3 month supply of prescription medication from Future Scripts (https://www.futurescripts.com/FutureScripts/), a subsidiary of Independence Blue Cross (https://www.ibx.com/index.jsp), was nothing more than logging in, clicking on what needed to be ordered, and then checking out. But just a few weeks ago, I noted that when I tried to do so by clicking the link https://portal.myfuturescripts.com/MyFutureScripts/mail_order_saml?redirectToMailOrder=true., I was informed that there was an error in logging into the site. Double checking the password was correct changed nothing. I called my family doctor’s office to have them send the prescriptions instead, and got a notification from Future Scripts that my order was being processed as well as a phone call to my home number asking me to verify my address (something I have never had to do before). I was given a deadline of August 31 at midnight to respond or the order would be canceled. I called and learned that the order had already shipped and the person who took my called was just as puzzled as I was that: a) I had gotten that call when everything about my order and shipping address was clear, and b) despite the need to confirm my address, the order shipped anyway before I called. She also informed me that it looked like Future Scripts was now going to be placing that same call with each order because my shipping address, as it has been, has been my office to assure that someone is present to get the order rather than have it sit in a hot (or cold) mailbox or be sent back if there is a signature required. I was further unpleasantly surprised to learn that Future Scripts was actually no longer administering my 3 month prescriptions because Independence Blue Cross had taken over that function. Moving forward, I would have to sign into https://www.ibx.com/index.jsp instead. I did that just to check and after a few false starts found that my Future Scripts password worked for that as well. I was also informed that Independence Blue Cross had NOT told its members of this change, and had instructed customer service to tell members who call Future Scripts to log into their website instead without providing any explanation about how such a change had been rendered without informing members about it. This in essence forces those who use the online ordering service to have to make a time consuming call to a toll free number, wading first through the irritating mechanical voice options asking numerous innocuous sounding questions that on a more sinister level seem designed to irritate and frustrate those who call. Sure, automated voice protocols save time and money for the company, but as with all things insurance related, more and more of the cost is shifted to us, the consumer/member/“covered lives” that these companies so depend upon for their existence. Just out of curiosity, I logged in again to Future Scripts mail order services today, but when I clicked the link noted earlier, this time I got a new message:

2020 Thank you for your interest in online pharmacy services. Our records indicate that you are not eligible for Pharmacy Benefits. If you feel you have received this message in error, please call the number on your ID card. Please refer to error code 2020.

I know I still have 3 month pharmacy benefits. The policy we have has not changed at all except to have gotten more expensive for the new year while offering less. I cannot imagine calling again to find out what I already know. What is troubling is that if I am getting that message, how many other people will be too and how many people will be sent into a panic as a result because of the information presented in such a message? How many phone calls to Future Scripts and/or Independence Blue Cross will that generate? One would think that such a change in pharmacy benefits management would have been made very clear to all covered members at the outset, but what incentive do they or any insurance company have to be proactive? Instances like these do nothing but promote the continued disgust and malice the public often feels toward insurance companies. During a time when premiums continue to increase for diminishing and more restrictive services and benefits, there is this to consider:

Thirty-three people who served as the CEO of a Blues plan for some or all of 2014 collectively earned more than $26 million in salary and about $102 million in total compensation, which includes bonuses, 401(k) retirement contributions and other incentives, according to data supplied by state regulators in response to The AIS Report’s Freedom of Information Act requests and other inquiries. https://aishealth.com/archive/nblu1015-01

The numbers were roughly the same in 2015 according to the AIS report for that year. http://www.streetinsider.com/Press+Releases/Despite+Flat+Salaries,+Blues+Plan+CEOs+Collectively+Earned+$102+Million+in+2014,+AIS+Newsletter+Reports/10931041.html

In 2014, Daniel J. Hilferty, the CEO of Independence Blue Cross, saw a 6.2% increase in his total compensation to nearly $3.8 million per year. I don’t begrudge anyone the opportunity to make a good, or even amazing living. In comparing Hilferty’s salary to that of a Hollywood star or a star athlete, it pales in comparison and would be considered modest. However, when one looks at the aggregate of all executive and board compensation packages across the insurance industry, it is quickly evident where the majority of the disposable income is going after accounting for usual business expenses – not to patient care. In 2015, his counterpart at UnitedHealth Group, Stephen Hemsley, received total compensation in 2015 of $14.9 million, David Cordani of Cigna – $14.5 million, Joseph Swedish of Anthem Blue Cross – $13.5 million, and Bruce Broussard of Humana – $10.2 million. George Paz of Express Scripts, a pharmacy benefits management company like Future Scripts, earned $12.9 million in 2015. http://medcitynews.com/2015/06/what-were-the-top-healthcare-ceo-salaries-last-year/

So where does this leave us as consumers, as physicians? As a doctor, I am constantly faced with challenges to my decisions, largely in the context of prescriptions and what insurers think is appropriate or “medically necessary.” I have written elsewhere about both prior authorizations and why generics not always a good thing, but it goes beyond that. I realize that there are finite dollars to spend and that cost containment is a sensible consideration in any industry or business. As a dramatic example, a person complaining of a headache should not automatically have a brain MRI, which is very expensive and most often overkill for what may resolve on its own with no consequences. As physicians we need to be ever mindful of listening to our patients and thinking about the problem(s) presented as opposed to knee jerk orders for testing and other consultations in the name of being “thorough.” Insurance benefit limits can serve as a reminder for that. However, the health insurance industry is unlike no other industry because the direct currency is human life, and insurers are continually translating, or converting, if you will, that currency into dollars. Decisions made are on an endlessly cycling ethical slippery slope and there seems to be little that can be done at present to stop that process. But that is not to suggest that we are paralyzed and can do nothing. Change is always inevitable, so it would be up to us to try to direct that change in a positive direction.

For change to happen, there would have to be a consistent and sustained effort that speaks the monetary language of insurance companies. Employers, as represented by their human resources departments, need to work on harder negotiations with insurance companies. The larger the employer, the louder the voice. Joining health insurance purchasing cooperatives is one way to enhance bargaining power. A health insurance co-op (consumer operated and oriented plan) is not a new idea, and some of the first such groups began to appear in the US in the 1990’s. Elliott Wicks of the Economic and Social Research Institute wrote about this in 2002 in an issue brief for The Commonwealth Funds Task Force on the Future of Health Insurance. (http://www.commonwealthfund.org/usr_doc/wicks_coops.pdf) In it he noted that at that time there had been a number of successful co-ops, but also numerous failures and he reviewed the various reasons for those failures as well as for the successes. One point he raised that was striking was this:

In the future, co-ops might be able to offer more attractive prices, but that would depend on reaching “critical mass” size. To offer attractive prices, a co-op has to be able to realize administrative savings and/or have bargaining leverage with health plans. Both these conditions require that co-ops control significant market shares

But he also realized that it is difficult to reach that “critical mass size,” and warned against co-ops becoming a vehicle for pooling high, medium and low risk employers because of possible “adverse selection.”

In 1995 there were at least nine states that had formed some type of health insurance purchasing cooperative (HPC) or alliance. By early 2009, there were at least 28 states with such cooperatives mandated by state law or regulation. The federal government has also been involved in the creation of co-ops. Indeed, one mandate by the government was that a co-op “must operate with a strong consumer focus, including timeliness, responsiveness, and accountability to members in accordance with regulations to be promulgated by the Secretary of HHS.” For a more in depth review of the current state of co-ops, I refer the reader to http://www.ncsl.org/research/health/purchasing-coops-and-alliances-for-health.aspx.

While I think co-ops are a valid concept, it seems that a number have failed, though many continue to exist and do well. The bigger issue we face is the amount of power wielded by insurers. Who is regulating them? Among insurers, for 2016 Blue Cross/Blue Shield contributed the most money to political campaigns and parties at $6,555,994, while the total for the insurance industry for 2016 thus far has been $75,672,091. https://www.opensecrets.org/lobby/indusclient.php?id=F09

During the 2012 election cycle, the insurance industry contributed a record $58.7 million to federal parties, candidates and outside spending groups https://www.opensecrets.org/industries/indus.php?ind=F09

While a discussion of PAC’s, lobbying and campaign contributions is beyond the scope of this essay, the point here is clear. The language of currency is universally understood and is perhaps the most effective form of communication, which is how insurance companies have been permitted to use loopholes such as ERISA (see a previous blog entry) and avoid litigation as well as more definite federal and state control of how they operate. The net effect has been a good enough immunization against social forces or consumer discontent that might otherwise ultimately force a change in restrictive processes such as prior authorizations, dosage limitations and other forms of treatment denial. The argument on their part has always been that they are not denying treatment, but rather refusing to authorize it, which means it will not be reimbursed. Again, currency is the loudest and most effective voice.

Perhaps, though, there is hope kindling at present. As I have reported elsewhere, litigation against insurance companies is beginning to become more commonplace. For instance, there is the lawsuit in New York against UnitedHealth Group for violation of mental health parity laws. And more recently, United States Attorney General Loretta E. Lynch recently announced that the federal government, in an effort to ensure competition and fair pricing, is suing to block the proposed Anthem Blue Cross-Cigna and Aetna-Humana mergers. Listen here as Bill Baer, the Antitrust Chief of the Justice Department, explains what is happening: http://www.nytimes.com/2016/07/22/business/dealbook/us-sues-to-block-anthem-cigna-and-aetna-humana-mergers.html?_r=0

UnitedHealth Group had announced in April it was pulling out of the health insurance marketplace established by the Affordable Care Act (Obamacare). Humana and Aetna more recently announced the same intentions. All are claiming financial losses because individuals who might not otherwise have been insured are getting insured and tend to be sicker, according to reports, which means more money HAS to be spent on patient care, driving down corporate profits. Is a CEO seeing a total compensation of over $10 million really going to feel that? Perhaps – it’s not for me to say. But crying poor all of a sudden because a company has to do what it was originally intended to do – insure people for health care coverage – is ethically sickening.

If it weren’t so tragic it would be funny: the ongoing prior authorization nightmare

My latest entry will discuss yet another set of incidents of egregious behavior on the part of an insurer. This time it is involves a series of cases handled by Future Scripts prior authorizations department as well as their mail order pharmacy. Future Scripts which has a pharmacy benefits management arrangement with Independence Blue Cross.
https://www.ibx.com/individuals/member_resources/pharmacy/
In one particular incident, Future Scripts  http://Future Scripts received the patient’s mail order for generic Concerta, an ADHD medication, around October 1. Two weeks later the patient had yet to receive the mail order three month supply, though Future Scripts left a message on her home phone “apologizing” for the delay and then giving their toll free number to call with questions. To make matters worse, the mail order form explicitly stated that the shipment was to go to her father’s office because he would be there to receive it whereas if nobody were home when it came to the house, it would be sent back because it requires a signature given that it is a controlled substance. Of course, for the second order in a row, Future Scripts sent it to her home, either completely ignoring the shipping address or failing to read the form and using the default member address. Luckily for her, she still got it, albeit 2 weeks late, because the postal carrier failed to follow through with instructions to get a signature, and that was after Future Scripts apparently talked with her local post office to assure that would be the case. A call to a Future Scripts supervisor produced admission of the error in shipping as well as a promise to “get to the bottom of why that happened.” To her dismay, she opened the bottle and the pills were not the same as the last prescription. Indeed, they were not the specified authorized generic by Actavis, but rather one that had been downgraded by the FDA to a BX rating, which means it is no longer considered bioequivalent. She had gotten this once before prior to knowledge that the change in rating had taken place and its clinical effect did not last through her day and she had more side effects as well (anxiety, headache) compared to either the actual brand or the Actavis generic. For more about this, check http://www.fda.gov/Drugs/DrugSafety/ucm422568.htm

New prescriptions were then provided to her, one for the 30 day supply she needed to get at the pharmacy and another 90 day prescription. Future Scripts, after being demanded to to so, refunded the copay she paid for the wrong prescription. She went to fill the 30 day prescription and…..a NEW prior authorization was required for an override, given she had just received the previous prescription last week. Imagine that?! Future Scripts informed me that they could (or would) not authorize from their end it but instead would require that a new prior authorization request be sent for their review, which sometimes takes two separate attempts, as I have often found that my first request is completely ignored. Many times I send the request again, only to get back a puzzling response that there is already an authorization in place or the ubiquitous but nebulous request that “more information is needed” (which is usually just a repeat of everything I have already provided and nothing more than an answer to their request for more information). She still does not have that authorization as of this writing and therefore still is without the proper medication.

In another series of Future Scripts mishaps with a patient’s medication that evoked the old Keystone Cops (https://en.wikipedia.org/wiki/Keystone_Cops)
I had sent an authorization for an antidepressant, Fetzima, for a patient who was in need of this. It took several attempts, and multiple replies to the “more information needed” type of requests, to get it approved. Things were fine from that end but the medication did not work for her, so it was changed to another drug in its class, Pristiq. Each time I sent the prior authorization request that Future Scripts demanded, (the medication was refused at the pharmacy because Future Scripts was refusing coverage till the prior authorization was completed), I received the following response repeatedly:

The above drug does not require review for the member listed above because null Member may have the prescription filled with applicable cost-sharing.

Repeated attempts to get Future Scripts to clarify this were met with the same letter. This occurred toward the middle through the end of September and as of this writing at the end of October we still have no answer. Fortunately I have been able to supply her with samples while we are still trying to get the issue resolved.

Future Scripts has really been on a roll lately. There is yet one other example I would like to highlight for my readers. I recently evaluated a new patient and diagnosed her with bipolar disorder. Often, people with this illness suffer from chronic sleep problems and she was no exception. The generic form of the sleep drug Lunesta was prescribed because it was one that she had not yet tried; others tried had failed. Given the severity of her sleep problems dating back to childhood, I decided that the 3 mg dose – the maximum dose – would be the most clinically appropriate choice. In their infinite wisdom, Future Scripts, despite never evaluating my patient, determined that that was not the case and after sending again two requests they informed me that the 1 mg and 2 mg options would need to be tried and shown to fail before they would consider the 3 mg strength. I played the game, resubmitted a request, and got yet another denial – for 3 mg, AGAIN. I submitted the lower dose request again and got back this reply:

The above drug does not require review for the member listed above because generic Eszopiclone 1 mg and 2 mg do not require prior authorization; the patient must receive a 30 day trial and have therapeutic failure to one of the two aforementioned strengths of Eszopiclone to receive approval for Lunesta/Eszopiclone 3 mg. Member may have prescription filled with the applicable cost-sharing.

What was not clear then was why the lower dose was still being denied at the pharmacy.

Clearly, something is terribly wrong with the way insurance companies can interfere in patient care. Perhaps there is some reason to take heart, though, based on a recent decision rendered in the US Court of Appeals, which ruled in favor of NYSPA (New York State Psychiatric Association) and the APA (American Psychiatric Association against UHC (United Healthcare), permitting a lawsuit to go forward against UHC for violating the federal parity law for mental health and dismissed all objections raised by UHC, which opens the doors for future claims against insurers. Maybe this is the first step to erode the ERISA shield insurers hide behind when making administrative decisions that interfere with or compromise clinical care. For more about that read here: http://www.nyspsych.org/index.php?option=com_content&view=article&id=304%3Aunited-healthcare-decision-8-20-15a&catid=20%3Asite-content

For more about the impact of ERISA on health care, read here:
http://www.huffingtonpost.com/wendell-potter/congress-needs-to-close-l_b_2271531.html
http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=1099&context=yjhple

If you are a patient reading this, collaborate with your doctor to fight against denials of treatment, whether it is a prescription or some other aspect of your care. Remember, if you have a grievance you can also submit a complaint to your state’s insurance commission. http://www.naic.org/state_web_map.htm
Physicians and other health care providers, I know how time consuming this process typically is and I know the frustration it causes, but we are often both the front line and the last line of defense for our patients, many of whom don’t have the resources or energy to stand up to their insurance companies. It is incumbent upon us to be advocates, and if we can’t personally to designate someone on our staff to do so to meet patient needs.