From Red Lawhern, Ph.D.
On January 1, 2019, new rules for Medicare Part D reimbursement will go into effect. These rules authorize insurance providers to conduct so-called “safety edits” when a patient’s prescriptions exceed one of two thresholds.
Pharmacist and Doctor must conduct a safety review and file a special diagnostic code before the pharmacist will be authorized to bill Medicare for filling or renewing any prescription for opioid pain relievers which exceeds a morphine milligram equivalent daily dose of 90 to 200 MMEDD.
Insurance providers are also authorized to deny Medicare reimbursement for any prescription which brings a patient’s opioid dose to 200 MMEDD or more. This denial is subject to an appeal by the doctor, in which the insurer is the sole authority in determining whether Medicare will reimburse.
The natural outcome of this bureaucratic process will be to deny reimbursement for effective pain relief to many of the 1.6 million Medicare patients who are now maintained on 90 MMEDD or more. Many private insurance plans will also implement these restrictions on pain management. More doctors will be driven out of pain management practice. More patients may be driven into suicide by medical or psychological collapse.
I have prepared a petition to the HHS Centers for Medicare and Medicaid, demanding that “safety edit” rules be suspended for at least one year, pending publication of recommendations from the HHS Inter Agency Task Force on Best Practices in Pain Management, to Congress. I hope to send this petition to CMS by Thursday November 1, and I’m working to post the petition and its supporting documents to an archive of my published work where people can read it on-line.
Especially if you have ever been a medical professional or paraprofessional (physician, PA, nurse, psychologist, medical assistant, patient advocate, diagnostic coder, etc), I invite you to send me email at lawhern@hotmail.com to obtain a copy of the petition. If you agree with its content, you can then send me an email titled “endorsement”, with your name and credentials.
I will post a link when I’ve gotten all of the materials of this petition placed in an online archive.
Please join me to inform CMS that they are about to do something grossly stupid and destructive to hundreds of thousands of people.
So now Medicare are granted itself the right to practice medicine… since one of the basics of the practice of medicine is starting, changing, stopping a pt’s therapy.
Also they are using the flawed MME conversion formulas that have same or similar foot notes:
“Published equianalgesic ratios are considered crude estimates at best and therefore it is imperative that careful consideration is given to individualizing the dose of the selected opioid. Dosage titration of the new opioid should be completed slowly and with frequent monitoring. “
Is Medicare setting up a “mine field” for the pharmacists and the prescriber… for a long time the DEA has stated that it is a RED FLAG for a pharmacy to fill a controlled med for CASH when the pt has INSURANCE… because that is what substance abusers/diverters do and everyone knows that whatever substance abuser/diverters do that it has to apply to chronic pain pts.
So pts should expect to be denied to pay CASH for any opiates prescribed above what Medicare allows.
There also seems to be no accommodation for pts who are fast or ultra fast opiate metabolizers that have a medical necessity for higher/more frequent doses. It would seem that Medicare is trying turn the “art of medicine” into the statistical appropriate medication dosing… at least when it comes to opiates.
This is not going to end well for a lot of chronic pain pts, but maybe this is the bureaucracy’s means of cutting the cost of Medicare/Medicaid/SS. Since the “insurance company” is a for-profit business… could they be held responsible for assisting suicide for pts they refuse to fill above accepted MME/day doses.
Filed under: General Problems
I just want to say thank you, to Pharmacy Steve and mr. Lawhorn for all they do for us pain patients. Unfortunately it looks like it just falls on deaf ears, looks like we’re just all doomed to die.