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Coordination of care is one of the hidden dysfunctional aspects of medical care. The problem is that coordination of care is not reimbursed by insurance companies. Providers are expected to do the right thing and contact other providers between clients.

From the outside looking in, that would appear to make sense. Good medical care requires consulting with other providers to ensure everyone is working on the same plan and not against each other.

However, the economic crunch on medicine has been on for the past decade. Physicians and other providers are making less income than at anytime in the past generation. Providers are pushed to be more efficient. The result is that coordination of care gets less attention. This problem promises only to get worse with further cuts in Medicare and insurance reimbursement inevitable. If coordination of care remains non-reimbursed, quality will continue to suffer.

McClatchy Washington Bureau

Elijah Mense, a talkative 5-year old with dark curly hair, is very sick and his family doesn't know exactly why.

They know some of what's wrong. But not everything. So they've been tossed from one specialist to the next. "I learned up here the doctors don't work together," says his mother, Serene Mense.

She has butted up against a serious weakness in the U.S. medical system: Lack of coordination among doctors.

Insurance won't pay a doctor to coordinate care in a complex case, and it's difficult to do. The doctor has to contact all the other doctors involved, see that test recommendations are carried out, and battle with insurance companies over coverage for specific treatments.

Yet a complicated case like Elijah's clearly demands such coordination.

Corpus Callosum has great post about an article that appeared in the New England Journal of Medicine. He brimes with pride at the "venerable" journals departure from it's usual decorum in commenting on Medicare Part D.

It is a worthy read, and a withering criticism from a high respected journal with starched credentials. Here is an excerpt from the grand ol' journal.

Part “D” for “Defective” — The Medicare Drug-Benefit Chaos

True, the program provides drug benefits for some Americans who previously had none. But because of its strange design, enrollment is falling far short of expectations. Officials in the Bush administration boasted that 25 million people are receiving benefits through Medicare Part D. But the government's data reveal that about 20 million of them already had adequate drug coverage through Medicaid, their employers or unions, or health maintenance organizations; as of late February, the new benefit was providing only 12 percent of the elderly with coverage they did not already have.1

In many cases, the program worsened patients' situations, with a particularly heavy burden falling on indigent Medicaid enrollees. Before the new entitlement, most had virtually all their medications covered fully by the states. But on January 1, 6.2 million of these vulnerable elderly were reassigned to one of the private insurance companies designated by Medicare to run its program. Word of these arrangements didn't always reach the patients, insurers, or pharmacies accurately, and tens of thousands of indigent patients were told to get prior authorization, pay a large initial deductible, or make substantial copayments for regularly used medicines they previously received at no cost.2 Thousands discovered that the drugs they had been taking for years were not covered by their new insurers. Clinical crises ensued, and 37 states had to provide emergency payments for frail citizens.3

Despite its youth, the Medicare drug benefit is already chronically ill. But with extensive rehabilitation, it could go on for years, albeit with impaired functional capacity. Debate continues over whether its early spasticity was caused by inept management of its birth or a genetic disorder present at its creation. Proponents of the first explanation suggest that Medicare and its private insurers were not ready for the millions of applicants and hundreds of millions of prescriptions that poured in early in January, in a flood that they were ill prepared to handle.

Alternatively, the lethal flaw may not have been in the implementation of the program but in its conception. The program's poor functioning may result from mutations at multiple loci: the reliance on private companies to shape a public program and contain use of costly medications; the expectation that most older Americans would readily choose among myriad competing plans, making necessary comparisons on the Internet; the right granted insurers to require patients to switch to the companies' "preferred drugs"; and the vision that millions of disabled patients — many cognitively impaired, chronically ill, poorly educated, unable to speak English well, or all of the above — would successfully work the new system as enlightened consumers. Instead, the new public–private partnership expressed the worst traits of each parent. The government was ill equipped to coordinate the complexity it created, and the companies were too fragmented and bottom line–driven to fulfill this vital public health function.

An informed consumer is critical to ensure quality care. The mental health professional needs feedback from the client to ensure care is effective. That is as much true for counselors as it is for psychiatrists.

Insurance companies and now Medical Assistance have been increasingly using medication "formularies" to control the cost of their medication budget. Formularies limit the choice of medication for which the insurance company will pay. Often that is because there are a choice between brand name and generic medications or a choice among a number of equivalent brand names. Formularies also limit access to newly developed medications that are considered "experimental." While there may be some notable exceptions, formularies exist primarily to save money. Insurance companies and generic medication manufacturers insist that generic are as high quality as name brands.

The Federal Drug Administration (FDA) sets standards that say generics must be equivalent in quality and potency. However, as with all things, you get what you pay for. Generic manufacturers have to cut corners to be able to offer a cheaper product. Generics may work just fine for most people and most medications, however, there will be exceptions.

Psychotropic medications are no exception. WebMD's Anxiety and Stress Management Blog has an introduction to the topic.

Patients have been telling me for years that there's a problem with their medications when they are switched to generics. I've heard this when I worked in psychiatric hospitals and in private practice and, sometimes, on the board.

[...]The journal Clinical Therapy in both 2003 and 2004 noted that there is a difference between brand and generic medications. The journal Hospital Practice also looked at the differences between generics and brand benzodiazepines. The differences can, according to psychiatrists I've heard from, be as much as 20-30% in the bioavailability of the medication.

Simply put. this translates into the percent of a medication that can be absorbed and utilized. Some psychiatrists have noted that they've had to increase the dose of a generic as much as 50% to get the same effect they would get with the brand name.

As always, medication decisions should be a joint decision with your physician. The more the client understands her needs and her medications, the better the discussion and decision will be.

Having trouble with Medicare Part D? You aren't the only one.

Knight Ridder

Many of Medicare's poorest and most sickly patients are going without their medications because of administrative glitches, misinformation and confusion surrounding the new Medicare prescription drug benefit.

Experts had warned that many of the 6.4 million low-income people who get benefits from Medicare and Medicaid could miss out on their life-sustaining medicines when their drug coverage shifted on Jan. 1 from Medicaid to private plans sponsored by Medicare. In interviews, advocates for the elderly as well as lawmakers and seniors themselves indicated that that's happening. Some, such as Deborah King of New York, were placed automatically in new drug plans that don't cover their medications. Others were getting stuck with extra out-of-pocket fees because their new enrollment status couldn't be verified.

Medicare's contingency plan for patients who aren't enrolled in drug plans also is proving problematic. The agency wants pharmacists to give these customers short-term refills at no cost and bill Medicare later. But some pharmacists don't know about the agreement, and others are balking because they fear they won't be reimbursed.

"There's almost nothing that isn't going wrong," said Jeanne Finberg, an attorney for the National Senior Citizens Law Center in Oakland, Calif. "People are crying. They're calling their legislator's office in tears."

These problems and jammed phone lines that prevent pharmacists from confirming customers' plan enrollments mean that many patients can't get their medicine. While the extent of the problem is unclear, health experts say the situation is dangerous because those patients who get Medicare and Medicaid benefits have higher rates of chronic illness, disability, cognitive impairments and other health needs. Their lives and livelihoods depend on their medicine.

There is help available. NAMI-Minnesota has set up information sessions around the state. Get more Minnesota information here and here. NAMI should have resources here as well.

Contact your mental health provider for more individual help and to access medication assistance programs.