For once I thought I would start off one of my blogs bluntly without any sugar coating. So here it goes. One of the state provided health insurance plans in Massachusetts is called MassHealth. There are thousands of people, like myself, who are forced to take this insurance because we are living with HV/AIDS and do not have ANY alternatives. The only little wrinkle here is that MassHealth is one of the most poorly run, managed, and totally fucked up health insurance plans on the planet. I cannot even comprehend the level of damage and harm they have done by their stupidity, idiotic rules, and refusal to pay health care providers that are willing to accept their pathetic reimbursement rates and see patients with HIV, hepatitis, active substance abuse, the homeless, the severely mentally ill and other disenfranchised people in desperate need. They are simply and bluntly FUCK UPS of the first degree.
Now, I know my regular readers are just appalled at my candor and language, but I have a feeling they will get over it. New readers will have to get use it. This is just the way it is. So read on or don't, It is all up to you but I plan and saying what really needs to be said about MassHealth and make sure that our Governor, and the powers-that-be at MassHealth get a copy of this posting and see if ANYONE...maybe you Gov. Deval Patrick? or maybe the Secretary of Health and Human Services Dr.JudyAnn Bigby...will have the guts to look into this debacle that is most likely harming if not outright killing people. I am not expecting anything to happen so I stand no chance of being disappointed here.
Okay here is what I am dealing with today for my patients and for myself. Many of my MassHealth patients desperately need (yes, I even agree that that the drug cost is outrageous) a very expensive drug take nightly by injection to help them gain weight, fight HIV wasting syndrome, improved their HIV induced lipodystrophy of facial wasting, limb fat loss, and other metabolic disorders. This drug typically is a God send to many patients as they take it along with their antiretroviral therapy. They feel better, look better (and reduce the social stigmata of gross wasting syndrome), some very well done peer-reviewed research studies suggest that this drug (a form of human growth hormone) may even assist with viral suppression and increase CD4 counts. I have seen this drug literally pull some of my patients back from the brink of death when their wasting was severe.
All sounds great right? Well, here is the stupid kick in rubber parts for most us on MassHealth. Basically, you can only get this drug by having a willing health care provider go through mounds of paper work for the infamous "Prior Approval" process. Okay, I am willing to do this, I have long ago given up the hope that our health is NOT being dictated by faceless, nameless, and sometimes heartless beings that live in cave of MassHealth somewhere in Boston...kind of like the secured, non-disclosed location that use to run Dick Cheney off to every time someone said they might pop off George W. Bush. The bottom line is MassHealth and so many other insurance companies (yea, in conjunction with the greed of big Pharma) are the ones managing your health care in reality. My three graduate degrees, specialty certifications, honors, awards, publications, and decades of clinical experience do not really count. Some vaporized person of God knows what educational background makes the decision, and sends back into the ether if they are going to let me practice medicine and help someone or not.
Recently, I was standing in Coliseum in Italy and the first image that came to my mind was "thumbs up/thumbs down" of allowing a warrior to live or die by the Emperor and that Emperor was health care insurers in general and MassHealth in particular. It was a chilling realization.
I am going to use my recent bout of needing to change my ART due to mitocondrial toxicity, virological decline, weight loss and numerous other debilitating symptoms that I have blogged about. MassHealth started to DECLINE my life-enhancing growth hormone because I was SICK. As long as I was well, gaining weight, and my HIV was stable I had no trouble (except for repeating the mounds of unnecessary paper work) monthly to get growth hormone. Once my health took a nose dive and I lost weight, saw my CD4 count plummet, and felt like living hell off the medication it was denied once, and then again, and then again. All of which made my clinical spiral downward speed up and nearly killed me.
Ah, but take heart. I happen to be practicing in a clinical practice (maybe the only one on the entire Cape. The big time non-profit don’t seem to bother with such nasty stuff since they have government funding and tons of money so why should they care about patients as long as the funding keeps coming in as it does) that actually cares about our patients and my wonderful nurse practitioner sat down and wrote a two page letter of appeal to these geniuses at MassHealth pointing out that I clinically, ethically, and medically needed the support of continuing on growth hormone since I was VERY SICK. (Imagine that, I needed medication because I was sick, and not because I was well. Go figure.)
My NP pointed out the obvious stupidity of their policy, the impact on my health, and that she was frankly not going to stand for it anymore and watch me waste away while my HIV hopefully stabilized on new a new ART regimen. She asked for a prompt reply and for 3 to 6 months of approval of my medication. Oh, the prompt reply by the great faceless ones did happen, but only for ONE month. So I will have to show clinical improvement, gain weight, and improve my counts by the end of February so I can submit all of this paperwork again for the MassHealth Emperor to let me know if the Emperor is interested in letting me get better, or turn thumbs down and fuck me and my life threatening illness.
Of course, I could fill pages with other MassHealth, and others insurers "rules", to see who gets needed drugs or not but I do not have the time right now. I have to shove food down my throat, prayer that my new AIDS regimen is going to do the trick, and hit the gym first thing in the morning regardless of how I feel. After all I don't want to be thrown to lions...well, not yet anyway.
Richard,
This MassHealth situation sounds tragic and frustrating—but I would sign on to the service in a heartbeat. At least you are living in Massachusetts and enjoy universal rights to healthcare, even though policy and red tape pervert its effective delivery. Here in Florida—and most elsewhere in country—there is nothing like it and safety nets are few.
My generous COBRA period has recently expired and I have just calculated the full price for my anti-HIV regimen – two pills twice a day that have delivered near-perfect lab numbers for around 12 years – and it totals $20,400/year. I am in shock that these meds—one of them a first-generation NNRTI—still command these prices. It is even more obscene than your language.
And I’ve been asking myself if anyone is really worth (moral?) consuming resources—public and private—at that cost on a long-term basis. Certainly not if the recipient aims merely to exist, eat, defecate and perhaps tweak. Giving back has new imperative for me now.
Barak Obama is now president, and he promised to deliver healthcare access to all who need it—and I am counting on it more and more. Meanwhile, it is surprising that Governor Patrick is tolerating this MassHealth travesty.
Steven, Your point of "at least I have something to bitch about" is very well taken. Again, if you read back through my blogs and other writings the real problem is that health care in the greatest nation in the world is a face. Health care is a basic human right and NOT a privilege yet we treat it like it an expensive sports car that is for fun and enjoyment instead of the thing that keeps us alive and productive members of society. How many more studies do we need published that say this very same thing.
As far as counting on the new President to do anything of substance I hate to tell you that this is just not going to happen until health care is nationalized and a one-party system is set up. As First Lady, Mrs. Clinton did the grueling leg work but was shot down by the health care industry, many Republicans, and by people that simply hated her husband. First Lady Clinton really did have A LOT of the answers and they went up in smoke because of her (then) place in history, a blow job, and a husband that never knows (and still does not) when to simply shut the fuck up.
Just an update. I have sent this column to the Governor and the Secretary of Health and Human Services by email and snail mail. Guess what? TOTAL SILENCE. Maybe it is time I send it to the Boston Globe?
I agre with you Richard. My Husband had a heart attack and was forced not to work. We applied for masshealth insurance and as always given the run around. Finally we got it. But lorse behold more paper work to fill out. And more pamplets to read over and over again. He went to go and fill his perscription and was told masshealth has denied him his insurance. I get tired of calling to correct theese matters. Your lanquage is what I feel as well. Somebody has to say it. And let it be known.
God Bless you Richard.
Okay everybody...you are likely not going to enjoy my comments, but here goes. First off you are all getting MassHealth for free or for a small premium. So, to me you are already ahead. If you are unhappy with the services of MassHealth, then why don't you buy private insurance like the rest of us? I can guess...too expensive, right? Even if you could afford the handsome Blue Cross plan, would they pay for all of your prescriptions and all of your procedures? Not always! MassHealth is there to help, but it is not suppose to be the BEST possible coverage. Quite frankly, there isn't any BEST coverage, even in the private insurance world.
I have worked in healthcare most of my life. And now I help folks buy health insurance. The biggest problem I see out there is that folks are extremely uneducated about the landscape of healthcare in general and even more so in Massachusetts.
Did you know that Massachusetts is a Guarantee Issue state? That means that regardless of health profile you get the same rate as the next guy. When you buy health insurance in MA, your age and your zip code set the rate. And guess what? The insurance company has to to accept your application. So it doesn't matter if your are fighting a disease or if you are an elite athlete, if you are 40yo living in Boston, you pay the same premiums. Now there are different plans within each insurance company. And premiums will vary with the amount of risk the customer is willing to take in the form of copay or deductible. So because your health profile has no bearing on premuim (unlike any other kind of insurance), our premiums are high, because we cover everybody. You can't say that about almost every other state in the U.S.
Having said that, the only way for healthcare to be reformed is through Transparency of Cost. If we all knew what medicines, doctor's visits, operations, MRIs etc. cost AND we had to pay a percentage of that cost, healthcare would transform. WHY? Because all the providers and all the insurance companies would be forced to keep the customers happy. Right now, families are paying 15K or 18K per year for a health plan. That is crazy money. Why do people continue to pay? Because they think doctor's visits and MRIs are hundreds and thousands of dollars. Sometimes they are and sometimes they are not. Why is it that Mass General can charge $3000 for an MRI but Emerson Hospital charges $800? Same MRI. But if you never know and doctors never know, then why not continue to raise the costs for services if there isn't any checks and balances? Hospitals charge more, labs charge more...insurance companies have to pay claims...so they need more revenue from the customers to cover all those costs.
If folks had to pay for some of those procedures via a percentage, then they would shop around. Many community hospitals out perform the big teaching hospitals on infection rates, good outcomes, less complications, etc. Consumers would force providers to get better at delivering care more cost effectively, more efficiently and force an improved bedside manner. If folks had difficulty paying for some of the percentage, then they ought to continue to receive help from the Commonwealth.
Would you have a problem paying 10% of a doctors bill? Say you have 2 doctors to choose from...one that graduate from Harvard, has documented that he has done the surgery you need 500 times and has a low infection complication rate, the other graduated from a small medical college in the west and has had less experience. The first doctor charges $500 consult, the second $200 consult. You decided which physician is best. Let them compete for our business.
This is how we conduct business in almost every other part of our lives. Think about car insurance. If you own a car, you must buy car insurance. For sake of arguement, let's say your auto deductible is $500 and your premium is $2000/year. You have auto insurance to protect yourself if in an accident, to protect someone else if injured by your car, or if you wreck your car and need it repaired. Does your auto insurance pay for an oil change? Does it pay for a tune-up? Does it buy you winter tires? NO, NO, NO. If someone came to your house to sell you and Auto Plan that would include a tune-up, oil changes, car washes, winter tires, new windshield wipers every year, but charged your $10,000/year, would you buy that plan? Not likely, because you can buy all of those things for a lot less than the additional $8,000 in premium, right? The same thing can happen in healthcare. If doctors, like auto mechanics had to earn your business, healthcare delivery would improve, overall costs would decrease and therefore overall health insurance premiums would decrease as well. Freeing up more money to help those that need help.
On another note, folks need to get their priorities straight. Why do people complain if they have to pay $50 for a lab test, but don't think twice about blowing $50 on dinner or for a pair of shoes?
Thanks for the opportunity to share a different opinion.
Responsible Citizen
hi Richard, I like very much what you wrote about mass health. My family and I are going through a similar situation. Only my wife is dying from cancer. I've worked all my life. Then I lost my job that we have no health-insurance. We applied for mass health many weeks ago in the meantime, the bills just keep coming in. My wife goes for treatment at Dana-Farber Cancer Institute in Boston Massachusetts. We live in Massachusetts, just to give her a shot in the ass. So she can stay alive cost over $5000. I like to follow your blog. I hope you would visit mine. I'm very uneducated, but I try to put the word out and say what I feel I talk about Massachusetts on twitter all the time.finally sent us an insurance card for our son,he has covered 100%, probably because he is healthy. My wife is on lots of medication for pain and other things. My wife receives two treatments at Dana-Farber. Once every month, and once every three months for the other treatment. That's about $15,000. I didn't mean to say so much, but I really like reading your blog,maybe I can learn from you. Thanks Jim
Is there any way to log complaints about MassHealth procedures and poorest interpretation of the law? Seeing routine denials of trasportation requests by them because doctors are unable to fill out 1 page form to their liking. Never followup to fill out completely, simply denial int he style of Roman emperor you describe. Can we fight back?
Responsible Citizen, your view of healthcare appears to be somewhat simplistic for someone who has supposedly been involved with the health care industry for a number of years. I am going to provide you with two real examples as to how Mass Health is messed up. On September 1 2009 I was declared eligible for Social Security Disability. On September 1 2010 I became eligible for Medicare. It took four weeks of telephone conversations between me, Mass Health and yes even Medicare at one point to determine if I would still be eligible for Mass Health once Medicare took effect. Over the phone no one at Mass Health could tell me if I would still be eligible! The only way I know that I was eligible was when the premium statement came in the mail! So for four weeks I had to forgo all medical treatment because I did not know who would be paying for my treatment; me, Medicare, Mass Health or a combination of all three. The second example happened in the month of January 2011. I received two letters, one indicating that I was no longer eligible for Mass Health until I spent down just under eight thousand dollars in medical expenses. The next letter then told me that I was eligible for Mass Health and what the premium would be going forward. The problem is that both letters were written on the same day January 10, 2011 and were postmark on the same day which was a Friday January 14, 2011. So the question is; would a for profit health insures be as wasteful in the use of manpower, resources and postage as Mass Health actually is. And one more note just too top things off. It also seems that the only time I receive mailings from Mass Health is on Saturdays so I am left to ponder what exactly they are trying to tell me until Monday when I attempt to call them directly. There also seems to be this mentality that it is more than proper to force people to remain on hold for thirty-six minutes no matter what time of day or what day of the week someone calls in on. The main difference between calling in on a Monday and that of calling in on a Friday is that on Monday you are more than likely to be disconnected by the automated system than you are latter in the week!
Thank you for your time
David C Roy
P.S. I am currently trying to find a full time position even though I am not really capable of going back to work because the amount of stress as a result of dealing with Mass Health is higher than what ever stress could be placed on me from working a full time job!
Send it the Globe! Go all the way get on 20/20!!!
Why is there no place to complain about anything concerning Mass Health?? My husband has been prescribed Humira and ever since then is continually shut off. We call and are told that they had sent us renewal forms on such and such a date yet somehow we never receive them. Which is funny considering I'm on his list for authorized person and before Humira we would receive double notices concerning renewal (One for him and one sent to me for him at the same address). Another thing I noticed with Mass Health is with one of my children (who has degenerative disks) not only is he shut off even when we return the renewal form but they say they never receive it. Once we sent it back 3x (1 every 2 weeks ) and still they said they never received it. Until I sent it certified they would not admit to receiving the form. I now must pay for our forms to be sent in by certified mail every 3 months.
What I want to know is…If a surgery is scheduled can they shut you off during the middle of the surgery just so they can try to avoid paying for it, knowing full well that you may not be able to take care of the problem in the condition you may be in??
I have to totally AGREE with you on how fucked up the Mass Health System is ! Spending most of my 53 years in that screwed up state I now reside in a warmer and MUCH more pleasant location. I am currently stuck paying a 1 year old emergency bill to repair my credit( from an out of state hospital ) for my 9 year old son, while I was paying for "Ass Health". I had the unpleasant run in with ALL the rude shit heads that work at that " Romney-esque" agency. Ironically, the billing department is located in New Jersey. I would like SOMEONE to remind me whatthe hell my $$$ went towards ( Probably Duval's knee operation ! ). Regards and best of luck to all the poor bastards that continue dealing with that fucked up agency, from a former "Masshole"