Date: April 6, 1999
Interstitial Cystitis Network - Chat Log (© 1999, www.ic-network.com)
Featuring: Dr. Vincent Riccardi - American Medical Consumers
Topic: Y2K in Health Care Systems: How to Protect Yourself
<icnmgrjill> Tonights topic is computers, Y2K and health care. Dr. Riccardi is the owner of American Medical Consumers, which I first heard about four years ago here in our local support group. He works extesnively with patients in educating them about their medical rights. How to work with HMS's, How to keep custody and track of our medical records. We have had several icers who have had a very difficult time getting an HMO to approve a medication, such as elmiron, and, in those cases, American Medical Consumers can step in, for a fee, and serve as an advocate for the patient and, most of all, help patients themselves and take control of their medical care and records. They have a great web site over at medconsumer.com/P>
Tonight, he's here to share with us some comments about Y2K and how the new year could have an impact on pharmacy computers, health system computers and what we can do as patients to just plan carefully for that transition. Right Vic?
<Vic> Our goal is to make patients/consumers strong, not have them dependent on yeat another group of professionals.
<icnmgrjill> Vic, you've been involved in watching the health care industry as they talk about potential computer problems. Can you share with us what you've leraned about Y2K and what the health community is concerned about, if anything??
<Vic> Most of the health community is concerned about covering their own losses. I'm concerned about the consumers themselves.
<icnmgrjill> HMMM... LET'S EXPLAIN Y2K.. CAN YOU DO THAT FOR US??
<drvic> Y2K... IS a concern for any company that has computers. Many of the computers that were first built decades ago made no provision for the year 2000 and so.. companies around the world.. are now trying to make sure that their computers will run smoothly over the new year.
<drvic> Is it hype?? The answer is no. It's a serious problem. In the health community, the trade journals have been emphasizing doctors avoiding liability and companies avoiding liability and indirectly that helps the consumer but its the wrong approach. For example, very large computer systems funded by large companies should have no problem with y2k. They have the staff and resources to resolve the problem.
It's the medium size computer systems found in pharmacies that could be a problem. And also the computer systems and medical record systems of hospitals in particular. Just imagine what would happen if your local pharmacies computer failed and on January 2, you went in for your next prescription of elmiron and, guess what, no records. Therefore, in November and December... be sure you have a months supply to last you through January 2000.
<lmatsos> Does that mean if we use large co. like Wal mart we will be better off than our local guy?
<drvic> That's a good question lma! The answer is yeah.. the larger company computers are better prepared to handle Y2K. The problem is also going to be is that health plans only allow a thirty day supply. Will they be flexible and allow you to get an extra 30 day supply for january? You want to check into that now!!!
<icnmgrjill> So.. Dr. Vic. What you're telling us is that we should do some planning and ask some questions about the availability of medications in January. How can we do this and not offend our providers??
<drvic> All the providers know that there is a problem. That's what I meant about liability. They know that this is a problem. It will not offend them at all. If the doctor is offended by this type of question.. get another doctor.
<Lesa> Will our providers even be honest about it if we ask I wonder?
<drvic> My expectation is that they KNOW that they are on the line
<icnmgrjill> Dr. Vic... what are the health journals specifically saying.. what's your impression?? Are they doing enough??
<drvic> What the journals are saying is:
#1 Alert your patients to the fact that there might be problems and ask the patients to be patient and forgiving.
#2.. the main message is cover your tail!
I see that as the wrong approach. The approach should be.. how can I best help my patients and that's why the patients themselves should show some leadership here!
<icnmgrjill> One of the problems that IC patients can have is access to pain medications and that some doctors are particularly reluctant to give more. Would just having back up copies of our prescriptions be helpful?? What should we assemble.. as records??
<drvic> This is a good question. The doctor patient relationship is based on trust. You ought to be able to ask for a prescription to be filled ONLY if there is a problem. In otherwords, the physician would be asked to write an extra script with the understanding that it be filled only if there is a problem.
<icnmgrjill> So, let's try to visualize this for a second. It's November, the new year is getting close. As an active patient, what your telling me is that I should, if possible, get a months extra copy of my prescriptions to have on hand... if.. and only if...I can't get a refill on the old prescription because their computers are down, right?
<icnmgrjill> Does anyone have any questions.. comments?? Cricket.. you had a comment. Could you share that with the group??
<Cricket> Each time I see a doctor, I get a copy of the paperwork from that visit. All prescription info is on those papers. I've never been denied by any doc when asking for copies of the paperwork that goes in my chart.
<drvic> Good point. It's good to keep copies of your medical records but you've got to remember that the pharmacist can only act on a prescription itself not a copy of a record, so.. it would be great to have both!
<lmatsos> I am sure any doc would be glad to give you a new perscription if y2k happens.
<drvic> Lma.. on your question. The answer to that question is that it is a good strategy but the offices may be swamped and it may be difficult to get through... for a few days. The point is to be thinking about being in control and not the victim of a possible computer glitch!
Also...one other thing that you'll want to consider is medical appointments and procedures scheduled for the first few weeks of January. Depending upon if the hospital computer systems are working or not, if your procedure depends upon a doctor having old records in hand and they can't get those records, like x-rays, they may not be able to proceed or.. be sure you have hard copies of those records. So that you've got a complete information set to bring with you!
<Lesa> If the Y2K problem isn't resolved before Jan. 1....can we feel secure that everything will be 'up and running' again in a month?
<drvic> Lesa... all the people I have spoken to including those in the pharmacy industry this morning is YES! We expect everything will be up and running within a month! Inotherwords, if there are problems they can be fixed and, during the repair time, you just want to have some back up plans.
<Lesa> I find this to be somewhat scary..
<lmatsos> Why can't they get it resolved now? It shouldn't be that hard.
<drvic> Lesa.. part of the problem is that the concern is not knowing whether the problem will even show up or not. If it shows up... it will be treatable fairly rapidly, we just want to make sure you have what you need until the repair takes place.
<Cyster> Do the hosps & docs over there not keep hard copies of all your records??
<drvic> Cyster.. yes.. they do
<icnmgrjill> Let's switch gears! Since Dr. Vic is an expert at resolving medical problems with HMOs.. anyone have any questions for him?? problems getting meds??? procedures?"?? etc. etc.
<Lesa> What other avenues can be taken when denied a referral?
<drvic> Lesa.. great question! Most often the denial at the level of the medical group or IPA not at the level of the HMO so the first course of appeal is to the IPA.. not the hmo.
<icnmgrjill> whats an IPA??
<drvic> IPA is another name for a managed care medical group. Independent practice association. So, if you receive a denial, your first object is to
#1.. Talk to your doctor. How was the request worded? IF the doctor wrote the request "patients wants... " almost certainly the request will be denied But.. if the doctor says "this treatment is medically necessary" it is far more likely to be honored.
#2.. Have your doctor reissue the request with the proper language and make sure that he says that it is medically necessary. You've got to remember I was in a quality care meeting yesterday and I saw that happen exactly yesterday. The request said.. "patient wants" and it was denied. The point is this is not arm chair empathy.
<Lesa> How do you know when it's an IPA denial and not just your physician?
<drvic> I've actually seen it happen! I see this happen frequently. Lesa.. another good question! The answer is by looking at the actual request. A physician would deny it by writing a request to trigger a denial. I have done this. A physician needs to specify whether the procedure or treatment is medically necessary
<Lesa> Would a physician deny a referral if he/she felt they could 'solve' the problem themselves?
<drvic> ::chuckles:: The answer is Yes... but that should be explicitly stated. An example is that many physicians feel that they can handle mild asthma without referrals to an allergy specialist and that might be the case but it is a matter of discussing the matter explicitly with the patient.
<icnmgrjill> What about patients who have received two or three denials. My mother just did when she was requesting an propylene glycol free estrogen creme and the person who replied each time with the denial from the HMO wasn't even a doctor. Finally, she had her doctor write a letter.. and got it approved but she had to wait two months. Are there any HMOS that are notorious for denying patient requests?? who are your greatest challenges??
<drvic> In general, the larger HMOs are the more patient sensitive and the smaller hmos are struggling and they have less clear cut policies in terms of written policies and procedures. I think one of the best examples is Cigna. All across the country they have national policies that must be adhered to in 50 different states.
<drvic> An organization that has to deal with the whole country can't be quite so reviewer dependent. It does not depend upon the personalities of the reviewer. It relies more on national policy.
And.. the other thing I would bring up is that many HMOs have case manager systems where a person with an ongoing chronic problem is assigned a casse manager to help him or her work through the problem to the mutual benefit to the HMO and the patient. I would think that someone with IC might warrant having a case manager. So, ask, "Do I qualify for a case manager??" My wife is a case manager and we discuss this type of thing all the time
<Lesa> What about expiramental or 'new' procedures and treatments?
<drvic> Ahh.. thats a good question. The answer is going to depend upon the explicit language in the contract or evidence of coverage. If the language declares that experimental or investigational procedures are not to be paid for then that is the end of it. But if there is room for medical judgement especially if it is through a case manager, they have a chance.
<Lesa> Even if the GP feels it's medically necessary?
<drvic> Lesa.. it's irrelevant. If the contract language declares that experimental procedures will not be paid for.
<icnmgrjill> Some IC patientes have problems with getting coverage with the concern of "preexisting conditions" and that they won't be covered. What do you suggest? Isn't there a new law which states that hmos can't exclude patients on the basis of preexisting conditions?
<drvic> This is very complicated because it is not always clear what a preexisting condition is. I broke my neck 27 years ago and I have functioned very well paralyzed on my right side and it is unclear whether if I had problems tomorrow after functioning well for 27 years.
<drvic> If the insurance company would declare this a preexisting condition as opposed to something new my point is that sometimes the problems are a matter of definition and other times they are a matter of timing...when they are a matter of definition.. the insurance company wins.
<drvic> When they are a matter of timing, the patient has a chance of winning. As to laws, it would be at the state level and would vary
<Lesa> A matter of definition? Like cancer or HIV?
<drvic> Sometimes Lesa. I help people who have a tumor on the face and the surgery is denied as "cosmetic." They ignore the fact that it is a tumor so clarifying the definition of tumor as opposed to "cosmetic" can get the surgery done and approved.
<icnmgrjill> What about the patient who is reluctant to leave a poor HMO because they are concerned that they won't get coverage elsewhere?
<drvic> My suggestion is to see if you can identify a more sympathetic and thoughtful physician within the HMO.
<icnmgrjill> Do you recommend that people stay with an HMO for a lifetime, like Kaiser, if possible??? Or is it good to change on occasion??
<drvic> I do not recommend change for the sake of change. To me the most important issue is do you like your doctor and does your doctor serve your needs in that plan.. or other plans. I don't want to sound like I am emphasizing the abilities of the doctor but if you have a doctor you like you've got your job done. Stay with that person. That is much more important than the plan itself. Last call for questions! One or two more!
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© 1999 The IC Network, All rights reserved. This transcript may be reproduced for personal use only. If you do so reproduce, we ask only that you give credit to the source, the IC Network, and speakers, Dr. Vincent Riccardi and Jill Osborne. For additional use, please contact the ICN at (707)538-9442.