To those of you who followed my Caremark rants over the past two years, don’t gasp in shock, but I just got approval for Sticks’ meds after three years of paying for them. I have no idea what’s different today than three years ago, but I’m not lookin’ a gift prior authorization in the mouth. Just being grateful.

Technorati Tags: caremark, pbm, adhd, medications, treatment

I’ve posted it on the political blog here.  I hope you’ll read it and pass it along to others. 

I cannot say this enough — this is a film with which you may or may not agree, but you will THINK.  And thinking may just be the beginning of a conversation that takes us somewhere.

Technorati Tags: Sicko, Michael Moore, healthcare, universal health care, health care reform

This isn’t a gun control post. Don’t come here and comment on gun control issues because there’s plenty of places out there to do that. This post is about the failure of our mental health system to adequately treat someone who was described in 2005 as “mentally ill and in need of hospitalization, and presents an imminent danger to self or others as a result of mental illness”. It touches on politics because our government has inserted itself so deeply into our health care system. It grabs at me because I have to navigate that system each and every month in order to get the treatment necessary for Sticks’ and my ADHD.

Alexandra Zacharios-Haight writes:

Whether Cho Seung-Hui was ignored my his fellow students and faculty experiencing what Durkheim called anomie; was lonely, depressed and totally untreated; given psychotropic medication only and poorly monitored; not seen frequently enough by a culturally sensitive, experienced clinician (campuses often don’t make it a priority to employ the best and the brightest and kids and their parents often can’t afford better because insurance won’t pay)–one thing is clear there were signs that something was terribly wrong and these signs were not be dealt with adequately.

Establishing a therapeutic alliance (an authentic relationship) between patient and clinician is what determines outcome. Government, insurance companies and naïve laypersons who want to dictate policy, procedure and treatment need to get out of the way because there are lives to save.

Indeed. But what happened in Virginia happens every day. It is why there’s an epidemic of homeless, mentally ill people wandering the streets at night, seeking shelter, needing treatment. It happens to university students, to respectable young men and women who are at a critical juncture in their lives. It happened to a dear friend’s son. He won a full scholarship to a prestigious university and went off to college, where he began to slowly have a breakdown. His parents were unable to intervene because of HIPAA and his refusal to allow them access to his records. They tried and they tried and they tried to get him public assistance, but there was precious little available and by the time they were able to intervene at all, he had dropped out of school and was sleeping in his car, unwilling to receive the meager assistance available to him.

Ultimately it took jail and a sentence that included mandatory treatment in order for him to get the medication and therapy he needed. Think about that. To receive treatment for his illness he had to become a criminal. That’s wrong.

Deborah Lynn writes:

Usually the insurance companies find a way to either stall payments, or make it incredibly difficult for any normal person to figure out how to get insurance to cover mental health situations. The parents then either ignore the problem or hope that the mental health services in college will catch their child if he or she falls ill. All this systemic inadequacy must stop. The stakes are too high to be screwing around with the mental health of our kids.

Sound familiar? It should, particularly the part about getting insurance to cover mental health situations and then hoping they’ll get caught in college. It’s really time to let go of this.

Mental illness is an ILLNESS. It is an illness, and a chronic illness. It is treatable. It is as serious as cancer, or HIV, or diabetes or heart disease. But it is treatable. Let’s stop worrying about stigma and start worrying about treatment.

Cho was put on a brief hold, given medication with no follow-through, and released. Because he agreed to the hold voluntarily, there was no record of it when he purchased the guns and therefore no alert to the seller of the guns that he should not sell them. To him, it was a normal, everyday transaction. Everything was in compliance. There should have been a record of it. Why does it matter if his hold was voluntary? He was reported as being a danger to himself and others, and that record should have been part of the database that gun merchant checked.

The other theme running through this tragedy is whether the university did everything they could when his behavior raised flags. I’d say they went beyond the norm with him. In a university that size, to have the head of a department take on personal tutoring to assist him with his education is amazing to me. They certainly didn’t have the information to know that he was a danger to others, but were willing to make accommodations so that other students would not feel uncomfortable around him and he could still continue. I was truly amazed by how involved they were in trying to ensure that other students would be in a safe learning environment while helping him at the same time.

If we take away one lesson from this, let’s make it this one: There is a real need in this country to give serious attention to how mental illness is regarded and treated. We need mechanisms in place — safety latches — to assist people through whatever journey they are on emotionally. It cannot be done on daytime talk shows with panelists Tom Cruise and Dr. Phil opposing. It needs to be a part of the dialogue concerning healthcare in this country, how we handle privacy issues, and how we address cases where the illness causes the person to turn away from necessary treatment.

On a personal note, this is of concern to me because of the ADHD. Sticks has succeeded because he has been successfully treated. I will not have the same involvement in that treatment at this time next year. i think he will continue as he has. But I cannot be sure, and I know what kind of havoc can be wreaked with untreated ADHD.

There’s a reason I’m not a college graduate. Figure out what it might be.

Technorati Tags: ADHD, healthcare, mental health, mental illness, Cho Seung-Hui, college, HIPAA, bipolar disorder

Shareholders approved the CVS/Caremark merger, ending the battle with Express Scripts. What it means for consumers may not be much:

Robert M. Hayes, a consumer advocate and former antitrust lawyer, called the merger a “natural business move given the concentration in the entire pharmaceutical, manufacturing distribution and purchasing business.”

But he questioned whether any cost savings will get passed to consumers. “This kind of merger doesn’t naturally lead to lower consumer costs even if the merged company can buy drugs more cheaply,” said Hayes, president of Medicare Rights Center in New York.

This is what concerns me the most. After the executives and shareholders get the big payoffs promised as part of the deal, the future will be bigger profits in the pockets of the haves, and less money in the pockets of the have-nots. It doesn’t have to be that way — merging a PBM with a storefront pharmacy operation could mean nice consumer savings, but given Caremark’s past history, I’m doubting it.

Bonus Link: Why I think PBMs should be off the table in any debate about healthcare reform.

Technorati Tags: Caremark, CVS, merger, consumer, PBM, healthcare

“CaremarkCustomersSuck“  left a comment tonight pointing to Jobvent.com concerning the attitudes of current Caremark employees.

Keep in mind that this site encourages negativity, but still…it’s obvious there are issues between Caremark and its employees in addition to the rest of us who are beholden to their contract administration.

Technorati Tags: jobvent, employee relations

TheHealthCareBlog reports on a recent Federal Appeals Court case which worked to their benefit and participants’ detriment. The text of the AISHealth.com article is included in the post.

I want to put this in English for most people who aren’t fully steeped in the rules regarding benefits and fiduciaries. Basically, the appeals court ruled that Caremark was a contract administrator, nothing more, nothing less, and didn’t have to comply with the much more onerous requirements that a plan fiduciary would consider. Had they been a fiduciary, they would have had to act with a care to the “exclusive benefit” of the plan participants in a fashion which a “prudent man” who was well-versed in such matters would.

Had the court ruled that Caremark was a fiduciary, they would have had to show that their rebate schemes were for the exclusive benefit of the participants, which of course they aren’t. This was a dodged bullet by Caremark, but my guess is that the plaintiffs are not finished with this case. I think this will go forward to the Supremes, because this question of whether or not a contract administrator can exercise discretion is one that is critical to the health of patients and plans alike, and difficult to resolve. Until the courts actually interpret what is, and is not, subject to the requirements of ERISA (the federal law which defines most employee benefit plans), there will be the kind of abuse that Caremark continues to engage in to the benefit of insurance companies and the detriment of insureds.

If you read the quoted article on TheHealthCareBlog, keep in mind that it is written from the insurance company perspective and is definitely biased in that direction. When they make statements like

” PBM customers generally don’t want their PBMs to be fiduciaries. “Customers want the PBM to do what the Carpenters did here, enter into a contract,” she says. “You do not want them to be in charge of what this court calls ‘discretion.’ There is no discretion about it. In a contract, here it is, here is the price. It’s spelled out.”

…keep in mind that the “customers” they are referring to are insurance companies. Next to the gun lobbyists, the insurance lobby is one of the most powerful in the country. What the courts should be giving attention to is the underrepresented and very large group of insureds, who most certainly are at the discretion of PBMs, even PBMs who have gastroenterologists rule on psychiatric medications.

In other news, the Caremark/CVS merger is still under siege by Express Scripts. From a consumer standpoint, such a merger could be of benefit to anyone who has Caremark as a PBM, since it gives them storefront access to medications which presumably would be priced favorably to Caremark and by extension, patients and insurance companies. I see absolutely no consumer benefit to the merger of two PBMs — Caremark and ExpressScripts. In fact, it would be terrible for the consumer since the majority of insured prescriptions for Medicare and private insurance would be administered by one national PBM. That, in my opinion, creates a monopoly and puts far too much power in the hands of the PBMs.

It’s easy to tell how much is at stake just by watching the salvos over the bow by Caremark, CVS and ExpressScripts. What gets lost in the heat of battle is the folks like you and me, who pay lots of money for insurance and end up still paying lots of money for prescriptions, too.

Technorati Tags: CVS, merger, PBM, employee benefits, law

Today’s linkfest is all about Big Corporations, Big Religion and Big Money. It has some of my old-time favorites as well as some newer finds.

Via There’s Something About Harry and MobileTracker, the eye-popping story of Cingular Wireless’ tireless effort to bilk a senior citizen out of $31,000.00. It seems that 77-year old Oliver DeSofi’s cell phone was hijacked by Nicaraguan monkeys who proceeded to make around 166 calls per day on DeSofi’s phone. Read on for Cingular’s incredible response. The mind-boggling part of this story to me is how carelessly they dismissed this man’s protests over his bill.

My favorite PBM, Caremark, is having some problems with the pending merger with CVS. This stems from Caremark’s rejection of spurned suitor Express Scripts, Inc (another PBM) 26 billion dollar offer in favor of CVS’ 21 billion dollar offer. Why on earth would Caremark reject an offer that’s 5 billion (that’s BILLION) more? Because CVS agreed to a bunch of sweetheart deals with Caremark’s top executives that would guarantee them: a) big money; job protections; and indemnification from legal proceedings. The last one is a big one, given that there are two lawsuits pending right now alleging that by rejecting the Express Scripts offer, Caremark’s board breached their fiduciary duties, and also given that there is possible option backdating litigation looming. But just in case there’s any doubt in anyone’s mind about the true motives for just about everything Caremark does, this should erase it. Completely.

Bonus Links here and here. In case you still haven’t had enough, pharmgirl tells us why your pharmacist hates you so much.

Over on the Scientology front, we have incredible blather from Scientology leader David Miscavige that Tom Cruise is really the new Christ of Scientology, criticized today, and worshipped tomorrow. Actually, I think they have that backwards, but whatever. It’s such an arrogant and incredibly specious claim that it’s hard to even take it seriously, except it really was intended seriously. Christlike or not, he can’t sway Victoria Beckham over to the Dark Side because she “can’t see the point of joining something like that where you have to donate money.” Amen to that. Meanwhile, dahamsta wonders when we can expect the crucifixion? Indeed.

Away from the absurd into the frightening, though, concern that Scientology is invading Belgian schools through their back-door drug prevention scams, their intervention in a criminal case in an already-tragic murder case in Sudbury, MA (why should they have access to the accused’s medical records, after all?), and their blatant pimping of Tony Blair’s image in an effort to distort facts and try to associate Blair with their shill front, the CCHR.

Technorati Tags: Cingular, Caremark, Express Scripts, CVS, Scientology, Beckham, CCHR

Medscape (free registration) has a new interview published about substance abuse and ADHD. Some high (and low) points:

I particularly want to comment on 2 studies. One is the study presented by Bright[5] recently at the APA [American Psychiatric Association meeting], showing that more than 1 out of 5 adolescents who have ADHD have misused their drugs. That’s a very high number. And of them, 80% used short-acting drugs, short-acting stimulants, in comparison to long-acting [stimulants]. So these kids are already finding a differentiation.

That sounds depressing. It also runs counter to what I’ve read in other studies, which is that people with ADHD, if treated properly, are less prone to substance abuse than non-ADHDers. As I read further into the interview, I found clarification:

Dr. Jain: Sometimes quite dramatically. And, again, let me offer you a particular review I read recently, again by Steve Faraone and Tim Wilens,[7] published in 2003 in the Journal of Clinical Psychiatry. They did a meta-analysis of the 6 studies that have been published and 1 that was halfway analyzed. So they put it together to see what are the rates of abuse with poorly treated ADHD vs very well treated. And here is the interesting fact: your rates [of abuse] are cut in half. So here we have a condition which, if you treat it well, [greatly reduces] your risk of turning to substance abuse — not only is your risk cut in half, it actually falls into the same category as for those who do not have ADHD in the first place.

I think that’s the tragedy of this condition, and this class of highly effective medications for a disorder that can be very impairing. Our goal is to find interventions so that you can have your cake and eat it, too.

and this:

The impact, interestingly, is not just at one point in time. If you have ADHD that’s poorly diagnosed, or poorly treated for that matter, your risk starts climbing up in your early teenage years, 13 or 14. But the interesting thing is we have studies showing that the risk never goes away.[8]

Even individuals in their twenties, thirties, forties, or fifties, if they have ADHD, their risk is high. So the take-home message for us clinicians is, every time you run into someone with substance abuse, look out for ADHD. And every time you run into an individual with ADHD, make sure you’re optimally treating this patient and also watching out for substance abuse issues.

Going back to the first quote, it was very significant to me that there was a differentiation between short-acting medications and long-acting medications; specifically, the medications most prone to misuse were the short-acting medications.

The insurance companies give preference to the short-acting medications because they are generic and cheap. But the risk for abuse appears to be much, much higher. It seems clear that the inference to “well-treated” in the quotes following are suggesting that proper treatment includes long-acting medication, proper diagnosis and ongoing monitoring and therapy.

I can attest to this. The problem with short-acting medication is that by the time they are absorbed into the blood stream and reach full efficacy, they’re wearing off. That creates the ‘roller-coaster’ effect which lends itself to abuse , simply as a means to avoid that up-and-down feeling. The long-acting stimulants are very different — they’re absorbed in just about the same amount of time, but last for 8-10 hours. The wearing-off effect is vastly reduced, so there’s not a sense of feeling fine one minute and out of it the next.

If the insurance companies are truly interested in the health of their insureds they will compromise with regard to the bottom line on this and loosen the hold on the longer-acting stimulant medications.

Technorati Tags: medscape, ADD, drug abuse, ritalin, adderall, concerta, dexedrine