Hi Marion - this is a serious situation. One that many of my friends in Pasadena have had.
One thing that matters is the kind of Medicare you have (Advantage - PPO, HMO, , straight Medicare etc). Another, as you identify, is the location. Have you tried asking Medicare for help?
I will send you an email outside of substack to further discuss. I will also research how this is handled elsewhere and may wind up with a newsletter addressing it...Be well...Alan
I have recently returned from living in the San Francisco Bay Area for 10 years to an area on the central coast of California where I previously lived for 40+ years. I was covered by Kaiser Permanente in the Bay Area and was extremely satisfied with their excellent & efficient medical care. Here on the central coast I have found it nearly impossible to get an appointment with a primary care physician in less than a 5 to 6 (or longer) month wait because hundreds of doctors have left the area or have gone concierge. Where have all the doctors gone? They have moved on to more lucrative areas where the private insurance and Medicare rates of reimbursement are higher. That’s because the governmental powers that be have designated our area as “rural” (which is low) and the cost of living here has skyrocketed. They cannot afford to live here. My only recourse for a medical situation is the emergency room or an urgent care facility. If you have a chronic condition requiring care, you are out of luck. The situation for seniors is dire and no one knows how to remedy it. Local political representatives have tried for years to get the rate of reimbursement raised to no avail. Are there any suggestions out there?
Before I retired, for years I was in a Behavioral Pediatrics group that managed very difficult patients - Kids on the spectrum, with sleep disorders, severe anxiety, incipient bipolar, ADHD, OCD....you name it.
It was enraging to have our lives managed by algorithm at a distance. When we would phone it would take 20-30 minutes to get to a "supervisory" pharmacist, only to be told he had no "authority" to change the guidelines. Corporate structures operating under the cover of "Evidence-Based Medicine" - which often actually amounts to "expert opinion" (not evidence at all, and fairly useless) - have been reaping profits at the expense of patient care for a very long time.
Thanks Dr. Fahy. You've provided a good example where those who are not driven providing the best patient care impede those who are (like you). The organizations who oppose change are big but it can be done. Switzerland, Taiwan, and others have done so in recent years.
How would you characterized a situation where PBMs don't respect your provider's choice of a best medication? Instead, the practice seems to require sequentially trying more favored medications before being able to successfully ask for authorization of a preferred Rx. For example, my dermatologist recommends a topical version of ivermectin as the most effective medication for rosacea. But I've had to first try another two medications, one of which has a $130 copay for a tube of oinment. This looks like a ruse to avoid covering the Rx, and this is with a Medicare Advantage plan.
Also, do you recommend any timing or collective focus to contacting our representatives? They are about to leave for the holidays and are scrambling to get out of town to avoid extreme weather conditions. Is writing or calling now likely to get lost at the turn of the year?
Hi Marion - this is a serious situation. One that many of my friends in Pasadena have had.
One thing that matters is the kind of Medicare you have (Advantage - PPO, HMO, , straight Medicare etc). Another, as you identify, is the location. Have you tried asking Medicare for help?
https://www.medicare.gov/care-compare/?guidedSearch=Physician
is their site to try and find doctors for you.
I will send you an email outside of substack to further discuss. I will also research how this is handled elsewhere and may wind up with a newsletter addressing it...Be well...Alan
I have recently returned from living in the San Francisco Bay Area for 10 years to an area on the central coast of California where I previously lived for 40+ years. I was covered by Kaiser Permanente in the Bay Area and was extremely satisfied with their excellent & efficient medical care. Here on the central coast I have found it nearly impossible to get an appointment with a primary care physician in less than a 5 to 6 (or longer) month wait because hundreds of doctors have left the area or have gone concierge. Where have all the doctors gone? They have moved on to more lucrative areas where the private insurance and Medicare rates of reimbursement are higher. That’s because the governmental powers that be have designated our area as “rural” (which is low) and the cost of living here has skyrocketed. They cannot afford to live here. My only recourse for a medical situation is the emergency room or an urgent care facility. If you have a chronic condition requiring care, you are out of luck. The situation for seniors is dire and no one knows how to remedy it. Local political representatives have tried for years to get the rate of reimbursement raised to no avail. Are there any suggestions out there?
The PBM scam has been in place for decades.
Before I retired, for years I was in a Behavioral Pediatrics group that managed very difficult patients - Kids on the spectrum, with sleep disorders, severe anxiety, incipient bipolar, ADHD, OCD....you name it.
It was enraging to have our lives managed by algorithm at a distance. When we would phone it would take 20-30 minutes to get to a "supervisory" pharmacist, only to be told he had no "authority" to change the guidelines. Corporate structures operating under the cover of "Evidence-Based Medicine" - which often actually amounts to "expert opinion" (not evidence at all, and fairly useless) - have been reaping profits at the expense of patient care for a very long time.
Thanks Dr. Fahy. You've provided a good example where those who are not driven providing the best patient care impede those who are (like you). The organizations who oppose change are big but it can be done. Switzerland, Taiwan, and others have done so in recent years.
Alan:
How would you characterized a situation where PBMs don't respect your provider's choice of a best medication? Instead, the practice seems to require sequentially trying more favored medications before being able to successfully ask for authorization of a preferred Rx. For example, my dermatologist recommends a topical version of ivermectin as the most effective medication for rosacea. But I've had to first try another two medications, one of which has a $130 copay for a tube of oinment. This looks like a ruse to avoid covering the Rx, and this is with a Medicare Advantage plan.
Also, do you recommend any timing or collective focus to contacting our representatives? They are about to leave for the holidays and are scrambling to get out of town to avoid extreme weather conditions. Is writing or calling now likely to get lost at the turn of the year?