The Future Looks Bleak: Government-Sponsored Healthcare

Last week a patient complained that we weren’t taking care of her child’s needs. Any complaint is not good, and we take them all seriously. But in this case, nothing could be further from the truth. And the truth is of great importance for all of us who are facing the government run health care that is knocking fast and furious at our doors. That is why I am writing about it today.

The child is 7 months old. The mother came to me because her son was unable to keep any of his feedings down. And each time he vomited his nose became stuffy. He wheezed. He became hoarse. He had difficulty breathing. Breathing and eating are my business. And I think her concerns are sufficient cause for worry, don’t you? So after trying different formulas (and using various medications), we found one formula, nutramagen, worked well for him. This formula is partially digested and “hypoallergenic.”

So what’s the problem?

The mother is on Medicaid and we have to go through the process of getting prior approval known as pre-authorization. Our physician’s assistant, Jared Martin, takes care of these onerous little details that make modern medical practice so much fun. The first time it went somewhat like this (these are verbatim chart documentations):

9/25/09 “The pharmacy reports that nutramagen needs a new prior auth. I spoke with a Medicaid representative from emedNY (1-800-343-9000). He explained the prior auth was still valid, but the item code needed to be entered with a “by oral” modifier. This meant adding “BO” to the end of the item # when the pharmacist tries to bill it. I relayed this back to the pharmacist. They will call back if they have any further problems. Meanwhile they did give mom Nutramagen formula to cover patient’s needs.”

Okay? No way.

Mother cancels her next appointment. She makes several others and reschedules them on the day she was supposed to be seen. Only when she arrives does she tell us that she is low on formula. She has not increased the amount he gets and his growth has decrease a bit. But the baby is keeping it down! A triumph! The formula prescription is changed to reflect his greater needs.

One week later it has not yet been filled by the pharmancy. She calls us and tells us a provider ID number is needed. We tried to call her back. She had changed her phone number. We left messages when we got her new number. We finally connected. Here is what then occurred:

1/7/10: “I spoke with mom & pharmacy about obtaining prior auth for nutramagen since quantity was changed it apparently needed a new prior auth. I called Medicaid at 1-518-8161, then was instructed to call 1-800-343-9000, then was instructed to call 1-866-211-1736. After 30 minutes of automated bureaucracy, I was instructed to go to www.emedny.org for instruction to form 3615-01. At the end of this automation I was told to call 1-800-343-9000 (again) to obtain form 3615-01 because it is not available on the website!! I called 1-800-343-9000 (again) & had to explain that when babies grow they need more formula, and if they eat more formula the family needs to have more formula to meet their demand. I had to explain that we are simply trying to increase a baby’s formula because he now eats more formula than he did 5-6 months ago. They will MAIL (can’t fax it for reasons unknown) me the form & meanwhile the pharmacy has to call them at 1-800-343-9000 option 2 sub option 2 for a temporary override.”

Unbelievable? Well you better believe it. You can’t make this stuff up.  And no wonder NY State Medicaid costs are the highest in the nation and we have the largest ratio of civil servants to population.

The saga is not over. Of course the mother is frustrated. And so are we. And this is only going to get worse as the government becomes more and more involved in the delivery of healthcare. Hold onto your hats folks, it can only get worse.