Painting and Decorating Made Easier!

Posts tagged ‘people’

Painter’s World: The Physician/Group-Insurance Company Generic Collaboration

I’m about ready to pull my graying  hair out, and go bald.

 

I take a Brand name medication that requires a prescribing MD’s prior-authorization request to access. Suddenly, the M.D. decided to stop completing and submitting a prior-authorization form for the Brand name to the insurance company.

 

“Totally unnecessary. Generic is exactly the same as brand name.”

 

What was that? Try to convince the Major Pharmas of that one!

 

Take note, fellow healthcare consumers:

 

As of the end of 2015, over 3 billion, 874 million* Americans take a generic form of a Brand name prescription drug. The National Prescription Audit’s most recent report** shows that 84.3 percent of prescription sales are the generic compound. Total generic sales topped $1.7 trillion dollars between 2005 and 2014.

 

At least 70 percent of those 3,874,000 are taking the generic, versus Brand compound, because of one or more of the following reasons.

 

  1. Their insurance company – eg. employer group, individual, family, Medicare, HMO – approves and has in its RX formulary only the generic versions of the Brand name prescription.

 

  1. Their healthcare provider will not order the Brand name as – eg. “medically necessary,” “Fill with RX Brand only,” etc. Note: See “Important Note” below.

 

  1. The patients cannot afford the cost of the Brand name pharmaceutical products.

 

  1. The local in-network pharmacies carry, or will order, only the generic version(s) of the Brand name product.

 

  1. The healthcare provider’s group, and its insurance company, will not certify the physicians in the group to write prior-authorization requests for and to prescribe Brand name products, when a generic is available. Note: See “Important Note” below.

 

Important Note: This includes if and when the patient tries and cannot take any of the generic (s) of the Brand name product. This includes if and when the patient has tried and retried, unsuccessfully, to take all of the generic compounds on the market. This can even include when a hospital consulting specialist determines that a patient must go back to taking the Brand name product.

 

One smaller health insurance company has found a solution. Well, it would appear to be one…

 

In its pharmacy formulary, the company includes a “suspension”/liquid form of a particular Brand name product. It is considered a compounded, “Specialty drug. At a Specialty drug tier/level price. This tier or level usually carries the highest price drugs in the insurance company’s pharmacy formulary.

 

A patient is caught in a bind. No choices that really benefit him or her.

 

Five of the Patient’s Options

 

  1. The patient can take and stay on a generic, regardless of adverse reactions, interactions, etc.

 

  1. The patient can self-pay 100 percent of the retail cost of the Brand name prescription drug.

 

  1. The patient can order the Brand name product from a Canadian pharmacy, hopefully one with a good track record for prompt delivery and sound ethical practices.

 

  1. The patient can change from the prescribing physician to one that will submit that prior authorization request for Brand name only.

 

  1. The patient can switch to a similar Brand name product that is in the insurance company’s pharmacy formulary, and does not require a prior authorization.

          Cautions: A.Most Brand name products listed in the formulary will require prior-authorization.                 B. Also, many newer Brand options come with much higher price tags.

 

What about simply changing your medication?

TIP: It may be wise to change from a medication that’s working only if you have to do so.

 

Real World Scenario. It’s very interesting to see and hear the reaction of another, leading healthcare provider, when told that a prescribing physician refuses to support an established patient’s need to stay on a Brand name prescription medication.

 

M.D.: “Did he/she say why?”

PATIENT: “I won’t do it…It’s totally unnecessary. Generic is exactly the same as Brand.”

M.D.: Tilt of his head…His eyes lower…He shakes his head left-to-right. “Hummmm.”

 

Guess what! A few poignant letters, including to the company’s president/ceo and group medical director may have gotten them all talking again, and rethinking their prior authorization policies. We’ll let you know. Keep your patient/healthcare consumer fingers crossed.

 

SOURCES

* “Statista Report on (Generic) Pharmaceutical Products and Markets, for 2015.”

* Also, The Generic Pharmaceutical Association.

** National Prescription Audit (for Generics), Report May, 2016.

**********************************************************************

Responsible healthcare boils down to responsive treatment of the patient.

*********************************************************************

Many thanks for trying to do your best in your world.

And, thanks for visiting “Painting with Bob.”

Copyright 2016. Robert D. Hajtovik. All rights reserved.

Advertisements
Image

Painting with “SYMPHONY SAM”

STRADIVARIUS
My mother told me recently about “Symphony Sam.” That’s the name she gave the homeless man that played virtuoso-quality music with his violin, in Chicago’s Pedway. And, he handed out free copies of the official Vietnam Veterans of America newspaper.

 

She met him one morning, in the Pedway between Randolph Street and Michigan Avenue, and S. LaSalle Street. She took the underground walkway, when Chicago’s temperature dropped to the 30s (wind chill factor 20 degrees or lower), and freezing winds bit into one’s cheeks.

 

“Symphony Sam” was a Vietnam Veteran. He suffered from PTSD, the debilitating effects of Agent Orange, relentless pain from the shrapnel still in his back and legs, and major depression. He always wore “a frayed, dark blue suit” when he played in the Pedway. And, a “subtle smile of absolute acceptance.”

 

Prior to serving three tours of duty with the U. S. Marines, “Symphony Sam” taught music at Julliard. Also he played Second Violin, part-time, with the New York Philharmonic, and violin in the orchestra of an on-Broadway theatre.

 

WHAT DOES “Symphony Sam” HAVE TO DO WITH PAINTING?

 

After “Symphony Sam” was released from the military hospital in Japan, he returned to the United States. The only job he could get was painting sublet apartments for a New York City real estate company. He lived with a fellow Vietnam Veteran and his wife, in a small, three bedroom flat.

 

One Christmas, he ended up on a Greyhound Bus, as it pulled into the main terminal, in downtown Chicago. He told my mother that he never remembered buying a ticket, and getting on that bus.

 

He said that he checked into a cheap, but clean hotel on Randolph Street. He carried a few clothes in a small suitcase, and his Stradivarius violin. No painting tools.

 

The hotel’s manager helped “Symphony Sam” get little painting jobs at other small hotels, located in the Loop.

 

One night, he suffered a severe PTSD episode. He said that he’d been fortunate. All of his previous attacks, in New York and Chicago, had been mild ones. He ended up in Michael Reese Hospital on the South Side.

 

Since then, he’d been unable to work regularly. When he had enough money to get by, he stayed at that cheap hotel, managed by the friendly Sicilian. Usually, though, he “lived underneath the city…with a few friends…also Vietnam Vets.”

 

My mother saw “Symphony Sam” for the last time in 1989. The week before Christmas. “He wore a newer, used suit, and a pair of polished black boots,” she told me.

 

He told her that he had been living back at the hotel. He worked part-time doing repairs and painting for “a list of steady customers.” He called them “small hotel people.”

 

“Symphony Sam” seemed content,” Mom told me. But, her eyes told me a different story. A major concern of hers, over twenty-five years later.

 

Did “Symphony Sam” make it? For how long? In 1989, when she saw him last, he was over 55. PTSD and Agent Orange’s lung effects had become less manageable. Several common medical conditions had set in. “His newer suit hung on his frame, always very bony,” my mother recalled. “His eyes an eerie tornado green. . .”

 

“Florida has ‘Symphony Sams,’ too,” said my mother recently. On “FLASHPOINT,” two Central Florida homeless coalition officials were describing the modern housing facility to be built for the homeless in the area. A plea was made for major capital support from corporations.

 

What about the “foreclosure-bound” hotel that a church congregation and volunteers converted into studio efficiencies for the local homeless? (“Painting It: A Multi-Family ‘Home for the Homeless,” posted December 11-12, 2014.)

 

What about the abandoned mansion, turned into a transitional residence for the homeless? (Watch for: “Painting It: Existing Home for the Homeless,” to be posted December 23-24.)

 

What about “Symphony Sam?”

 

“I would offer these people a much quicker solution.” I told relatives during Thanksgiving.

 

“Constructing a new structure – a large transitional housing facility, for millions of dollars – could take a couple of years,” I explained. “The groups involved in the Central Florida project – facility – haven’t even selected the land yet.”

 

Here’s one proposal to help people like “Symphony Sam” have a safe, clean home – and a chance at a better life.

 

  1. Rescue a few smaller hotels and motels along U. S. Highway 192. The ones plagued by low occupancy rates, disrepair and damage, and the threat of foreclosure.
  2. Repair them. Reconfigure their rooms and public areas. Set up a central dining area for the homeless residents.
  3. Recruit homeless persons, who once worked as skilled construction workers. Put them to work. They can help in making certain repairs and reconfiguring the rooms and common (public) areas. Give them a chance to regain some of their dignity. Their basic skills, like riding a bike or typing, will come back to them.
  4. Offer these workers future housing there, when the property opens for occupancy.
  5. Give the homeless residents a good reason to take care of their respective room, and the overall property.
  6. Keep the housing as simple and practical as possible. Recycle whatever furniture, desks, fixtures, appliances, window treatments, kitchen ware, dishes, etc. that are in good condition. Repaint, re-stain and refinish all surfaces.

 

By the way, expensive wallcoverings, flooring, furniture, and state-of-the-art systems are unnecessary. Research and reports about homeless shelter accommodations show that “pricier” amenities tend to make persons just off the streets nervous, self-conscious, apprehensive, distrustful, and even ill.

 

Every community has a “Symphony Sam.” A person who still possesses the skills and abilities, the passion, and the interest to give back! To get off the street! To once again become a more productive part of the universe.

 

Every community has do-able options to meet the dire housing needs of the homeless. Every community has at least one existing multi-unit property, that can be converted in a time-cost-manpower efficient manner.

 

Our local hotel GMs and their staffs can do only so much. They can help only so much. Their resources are very limited. Their ability to use their properties – which they do not own – is very, very limited.

 

What needs to happen to provide safe and clean housing for the “Symphony Sams” in our respective communities? To get this job done sooner than two to three years after they become statistics?

 

Local entities such as the Central Florida Coalition on Homeless and Central Florida Foundation (http://www.cffound.org) are proactive, and motivated.

 

Special projects such as the “Reconstruction of Housing for the Homeless in America Project” focus on providing safe housing promptly.

 

Professional and trade projects like the AIA’s new redesign/rebuild internship project tap young talent. Among other things, they offer fresh, new approaches to “reconfiguring and retrofitting” solid existing structures into great multi-occupancy housing.

 

What is your community doing to get your homeless adults and children, into safe and clean housing?

 

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

“Best wishes for a healthy, safe and peaceful holiday season – and Year 2015.”

 

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Thank you for visiting “Painting with Bob.”

 

 

Tag Cloud