RE: (TxFinancialCoordinators) yet another question on Rx cov

[Guest guest]

Thanks, .

I appreciate your response. We are currently pretty much doing the same thing...

but the funding from our hospital for those that do not qualify for anything

else may not be something we can always rely on. Our social worker applies for

any and all grants that the pt may qualify for.. but sometimes this still does

not meet the pts needs. The question remains, can we refuse to transplant (or

even begin the evaluation) if we have concerns as to whether or not the patient

will be able to afford his post tx meds?

If a kidney comes in at 2am (for example), who, in your program re-evaluates

their existing drug coverage and makes the determination not to tx? I would

think this would be morally wrong to call a pt in for a kidney and then deny

them at the last minute due to financial issues. I think it's important to have

" all your ducks in a row " as they say, before even bringing the patient in. Of

course, we all know, sometimes all this still falls thru the cracks and problems

arise. As financial coordinators, part of our job is to be sure the patient is

financially able to go ahead w/the transplant.

yet another question on Rx coverag

Our center does not have an all or nothing policy. I have discussed it

withthe surgeons, who feel very uncomforatable about not listing

patients for financial reasons. We will evaluate the patient and discuss

the medication issue with them. If they are a good candidate, we will list

with the patietns understanding that Drug coverage must be acquired.

They can either position themselves to qualify for state assistance, get a

job that will provide benefits or do a combination of fundraising and

grants form drug companies.(this last option rarely works due to

stringent requirements) As a final option I can lookto the medical center

who has a charitable fund for just these kinds of situations.

If the patien comes up for transplant, we will re-evaluate their existing

drug coverage and make a determination to transplant at that time based

on access to meds.

PWM

SFMC Honolulu

[Guest guest]

Rusty,

I WISH Florida had a program like your bc! Unfortunately, our state Medicaid

program is not all that great (soon to get worse, I understand) and we have no

other state aid. I know that we have never prevented a transplant because of

lack of rx covge.... but this is an issue that has arisen more frequently of

late, and we fear it may eventually come to that.

I agree w/Joe.... it would be a great survey for the group. , is there any

way that we can do this on the listserv? I'd be happy to set it up (in my spare

time, ahem!)

a

RE: yet another question on Rx cov

hi paula... to the best of my knowledge we have never prevented someone from

being listed or transplanted strictly based on lack of rx coverage. If they

have medicare only we either try and get them michigan medicaid, or, a bc

medigap policy. that bc policy available in mich from bc costs about 90$ a

month and it covers the 20% of charges that medicare doesnt, including

immunosuppressives. We also have a person in the pharmacy who runs an indigent

drug program which sometimes helps. there are also various small grants and

such which our social workers can sometimes hook these patients up with which

helps a bit.

and I totally sympathize with your social workers feeling about not letting

people go forward who lack rx insurance. its probably the sing biggest post

transplant problem we encounter...from a financial aspect anyways. rusty

Rusty Ward

Financial Coordinator Liver Transplant Program

haroldw@...

>>> paula_summa@... 03/27 1:47 PM >>>

Hi all,

We have run across this problem many times, as I'm sure many of you

have.... but it seems with today's Rx coverage changing almost daily,

it's become more of a problem than ever before.

Please let me know what, if anything, is your program doing when you

are referred a new patient who has Medicare only or who has an

insurance plan with very limited or no Rx benefits? If you know that

the patient cannot afford their post tx meds, what do you do? Are you

turning them away and refusing to transplant those who you know that

they will not be able to afford their post tx meds? If they are not

eligible for state aid (which in Florida is pretty bad), do you tell

them right off the bat that if they cannot afford their meds (or co-

pays), you will not even evaluate them? Our social worker feels very

strongly about not even pursuing a patient if we know they can't

afford their Rx co-pays (whether it be the Medicare 20% for the

immunos, or whatever their insurance requires).... so I offered to do

an " informal survey " and find out what other centers are doing.....

all replies are greatly appreciated!

Thanks....

a

[Guest guest]

Hi Joe Robbins, glad that this question made you reply!

Thank you, and to everyone else who has replied. I know this is an ongoing

problem with all of us... and I don't see any solid answer. Each state has

different programs in place to help those in need, and some states have much

better programs than others. The drug companies' programs are geared to help the

indigent, and many don't come into play until the Medicare coverage

terminates.... so they are not always the answer, either. I am hoping to go to

SLC with lots of questions for our speakers and hopefully come home with lots of

GOOD answers. (by good, I mean ones that will be helpful to my program and to my

patients)

, I will work on some specific questions for a survey, and if Joe y

wants to help, that would be great. (spare time? what exactly IS that?!?)

a

yet another question on Rx coverage....

Hi all,

We have run across this problem many times, as I'm sure many of you

have.... but it seems with today's Rx coverage changing almost daily,

it's become more of a problem than ever before.

Please let me know what, if anything, is your program doing when you

are referred a new patient who has Medicare only or who has an

insurance plan with very limited or no Rx benefits? If you know that

the patient cannot afford their post tx meds, what do you do? Are you

turning them away and refusing to transplant those who you know that

they will not be able to afford their post tx meds? If they are not

eligible for state aid (which in Florida is pretty bad), do you tell

them right off the bat that if they cannot afford their meds (or co-

pays), you will not even evaluate them? Our social worker feels very

strongly about not even pursuing a patient if we know they can't

afford their Rx co-pays (whether it be the Medicare 20% for the

immunos, or whatever their insurance requires).... so I offered to do

an " informal survey " and find out what other centers are doing.....

all replies are greatly appreciated!

Thanks....

a

[Guest guest]

Hi everyone

This is a major problem we all face in our work as financial coordinators for

transplant patients. In our program, before a patient is even considered for

transplant, having adequate insurance and prescription coverage is a strong

consideration. If a patient does not have prescription coverage, they are

advised that until the appropriate coverage is obtained, the person cannot be

considered for transplant. However, they are offered other options such as, if

a patient has Medicare only, perhaps the person would qualify for a medical

assistance program or a medigap plan which offers a prescription plan.

However, this latter plan (medigap) can be costly for the patient. Also, if a

patient has Medicare only, they are counseled to look into some of the HMO

Medicare plans that are available, which for an additional premium per month

(anywhere from $0 to $100+, depending on which county you live in), this could

provide some prescription coverage (usually unlimited generic and limited

brand). The immunosuppression meds are " carved out " of these plans and are

covered the same as Medicare under the " medical " part of the plan. Some

patients may qualify for the drug company assistance plans, but these are

limited in scope and not available to many. Even though our center is in

Philadelphia, we do get a lot of patients from New Jersey, who because of

disability and/or age, may qualify for a state assistance program which will

cover the immunosuppression medications with the patient paying a small co-pay.

This program is purely income based, so some patients may not qualify for it,

even though they are disabled. Patients are advised to seek out all options

(with info from both the financial person (me) and our social worker).

I think this is an important issue, because if patients cannot afford or do not

have adequate coverage for immunos, they will not be able to maintain their

life-saving transplant. I also think this a good topic for open discussion

with our group.

>>> paula_summa@... 03/27/01 02:20PM >>>

Thanks, .

I appreciate your response. We are currently pretty much doing the same thing...

but the funding from our hospital for those that do not qualify for anything

else may not be something we can always rely on. Our social worker applies for

any and all grants that the pt may qualify for.. but sometimes this still does

not meet the pts needs. The question remains, can we refuse to transplant (or

even begin the evaluation) if we have concerns as to whether or not the patient

will be able to afford his post tx meds?

If a kidney comes in at 2am (for example), who, in your program re-evaluates

their existing drug coverage and makes the determination not to tx? I would

think this would be morally wrong to call a pt in for a kidney and then deny

them at the last minute due to financial issues. I think it's important to have

" all your ducks in a row " as they say, before even bringing the patient in. Of

course, we all know, sometimes all this still falls thru the cracks and problems

arise. As financial coordinators, part of our job is to be sure the patient is

financially able to go ahead w/the transplant.

yet another question on Rx coverag

Our center does not have an all or nothing policy. I have discussed it

withthe surgeons, who feel very uncomforatable about not listing

patients for financial reasons. We will evaluate the patient and discuss

the medication issue with them. If they are a good candidate, we will list

with the patietns understanding that Drug coverage must be acquired.

They can either position themselves to qualify for state assistance, get a

job that will provide benefits or do a combination of fundraising and

grants form drug companies.(this last option rarely works due to

stringent requirements) As a final option I can lookto the medical center

who has a charitable fund for just these kinds of situations.

If the patien comes up for transplant, we will re-evaluate their existing

drug coverage and make a determination to transplant at that time based

on access to meds.

PWM

SFMC Honolulu

[Guest guest]

Thanks, ! We, too, have a program that is designed to help our pts w/their

meds (we call it the " Patient Assistance Fund " , and it is run by myself, along

w/input from our social worker and pharmacist) The funding is from the hospital

itself (part of our budget) and we do an annual golf tournament to raise money

for it, as well. However, the funding is not unlimited, therefore, at some point

we feel we need to start saying no to free meds. The amount of money the

pharmacy can lose in giving out meds can be astronomical... thus the reason for

the recent concern.

RE: yet another question on Rx cov

Hey a - and everyone: At our center in Salt Lake City, we have

recently hired a " pharmacy charity coordinator " because of these issues.

It was brought to our attention the amazing amount of money that our

pharmacy is giving out in charity care meds to transplant patients. So

- our center does not deny evaluation nor transplant listing due to

inability to pay for prescriptions. And, our hospital takes the stand

that they will not let a patient lose their transplanted organ just

because he/she cannot afford meds. We do, however, counsel the patient

(as many of you have said in previous notes) to start looking for

alternative coverage and that this would be expected of him/her. Tricky

situation, for the patient and for the hospital. Thanks.

s

Salt Lake City, Utah

>>> paula_summa@... 03/27/01 11:47AM >>>

Hi all,

We have run across this problem many times, as I'm sure many of you

have.... but it seems with today's Rx coverage changing almost daily,

it's become more of a problem than ever before.

Please let me know what, if anything, is your program doing when you

are referred a new patient who has Medicare only or who has an

insurance plan with very limited or no Rx benefits? If you know that

the patient cannot afford their post tx meds, what do you do? Are you

turning them away and refusing to transplant those who you know that

they will not be able to afford their post tx meds? If they are not

eligible for state aid (which in Florida is pretty bad), do you tell

them right off the bat that if they cannot afford their meds (or co-

pays), you will not even evaluate them? Our social worker feels very

strongly about not even pursuing a patient if we know they can't

afford their Rx co-pays (whether it be the Medicare 20% for the

immunos, or whatever their insurance requires).... so I offered to do

an " informal survey " and find out what other centers are doing.....

all replies are greatly appreciated!

Thanks....

a

[Guest guest]

I like the idea of a " Change of Information " form ... can you fax me a copy,

? (fax # 407 303-2478)

I also started sending out annual letters to those on the waiting list, asking

for insurance updates... for those that actually reply, it works great, but I

have to say the return has been less than I had hoped for. I would love to be

able to check everyone's insurance on a monthly basis... or even quarterly....

but lack of time and staffing seems to be a major reason for not being able to

keep up with all the changes that take place thru-out the year. If the patient

doesn't notify us of insurance changes, they sometimes " fall thru the cracks " .

We have also had a few occasions when the pt was brought in for tx and the

insurance was different than what we had on record.. and thus the " challenge "

ensued! Rea's formula to check monthly sounds great, but is not always do-able.

Thanks again to all of you.... it's great to get back so many wonderful

responses!!

a

RE: yet another question on Rx cov

We also have a " Change of Information " form that is presented to the patient

when they come in to see the hepatologist before transplant, so that they

are presented with an opportunity to give us the new info at that time.

[(Aguiar, )] We started sending a form out to every pt on the waiting

list annually a couple of years ago when I was w/MGH (will be doing it here,

too). This helps catch not only the ins changes, but address changes,

phone# changes, pt's who have died...

In addition, I keep a log of patients whose insurance approval expires ea!

ch month, and I check with the insurance company to get re-approval and

confirmation that the patient is still active in the plan.

[(Aguiar, )] I also try to run all the pre-renal tx pts thru CWF 1-2

times/yr to see who's picked up Medicare & " forgotten " to tell me about it.

Time consuming, yes, but can help eliminate the need to get some tx auth's

if Medicare has slipped into the picture.

J. Aguiar

Beth Israel Deaconess, Boston

[Guest guest]

Hi a

We also use a Change of Information form which I just faxed to you. We keep a

hard copy in the patient's chart and also update the information in our

databases (both hospital and transplant). Hope the info helps. Take care -

see you in SLC, Arlene

>>> paula_summa@... 03/28/01 01:07PM >>>

I like the idea of a " Change of Information " form ... can you fax me a copy,

? (fax # 407 303-2478)

I also started sending out annual letters to those on the waiting list, asking

for insurance updates... for those that actually reply, it works great, but I

have to say the return has been less than I had hoped for. I would love to be

able to check everyone's insurance on a monthly basis... or even quarterly....

but lack of time and staffing seems to be a major reason for not being able to

keep up with all the changes that take place thru-out the year. If the patient

doesn't notify us of insurance changes, they sometimes " fall thru the cracks " .

We have also had a few occasions when the pt was brought in for tx and the

insurance was different than what we had on record.. and thus the " challenge "

ensued! Rea's formula to check monthly sounds great, but is not always do-able.

Thanks again to all of you.... it's great to get back so many wonderful

responses!!

a

RE: yet another question on Rx cov

We also have a " Change of Information " form that is presented to the patient

when they come in to see the hepatologist before transplant, so that they

are presented with an opportunity to give us the new info at that time.

[(Aguiar, )] We started sending a form out to every pt on the waiting

list annually a couple of years ago when I was w/MGH (will be doing it here,

too). This helps catch not only the ins changes, but address changes,

phone# changes, pt's who have died...

In addition, I keep a log of patients whose insurance approval expires ea!

ch month, and I check with the insurance company to get re-approval and

confirmation that the patient is still active in the plan.

[(Aguiar, )] I also try to run all the pre-renal tx pts thru CWF 1-2

times/yr to see who's picked up Medicare & " forgotten " to tell me about it.

Time consuming, yes, but can help eliminate the need to get some tx auth's

if Medicare has slipped into the picture.

J. Aguiar

Beth Israel Deaconess, Boston