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AG: Caremark To Pay MassHealth $2.6M For Not Reimbursing Pharmacy Claims

This just in from Massachusetts Attorney General Martha Coakley: Caremark, the national pharmacy benefits manager that also operates mail-order pharmacies, will pay $2.6 million to MassHealth — and $4.25 million in a multistate settlement — for failing to reimburse claims.

Mass. AG Martha Coakley (Wikimedia Commons)

Mass. AG Martha Coakley (Wikimedia Commons)

Here’s the AG’s news release:

A company responsible for processing and paying prescription drug claims will pay $2.6 million to the Massachusetts Medicaid Program (MassHealth) to settle allegations that the company failed to reimburse MassHealth for pharmacy claims paid on behalf of its subscribers, Attorney General Martha Coakley announced today.

Under the terms of the settlement with Massachusetts, Arkansas, California, Delaware, Louisiana and the Department of Justice, Caremark, L.L.C. will pay a total of $4.25 million. The $2.6 million paid to MassHealth represents approximately 63 percent of the total payment by Caremark.

“This settlement is the result of an investigation into allegations that Caremark failed to properly handle and reimburse pharmacy claims for certain customers in the Commonwealth, leaving MassHealth to foot the bill,” AG Coakley said. “Our office will continue to safeguard the taxpayers’ investment in programs designed to provide care and treatment to our most vulnerable citizens.”

Caremark, operated by CVS Caremark Corp., is a California limited liability corporation with its principal place of business located in Illinois. It operates as a Pharmacy Benefit Manager (PBM) throughout the United States and contracts with its client health plans to supply prescription drug distribution and claims processing to participants in the clients’ plans. Caremark also operates mail-order pharmacies, and contracts with retail pharmacies nationwide to dispense prescriptions to its Caremark Plan participants.

This investigation began in 1999 with the filing of a whistleblower lawsuit in United States District Court in San Antonio, Texas. The plaintiff in that case amended her complaint in 2005 to add claims on behalf of the Commonwealth under the Massachusetts False Claims Act.

The investigation reviewed allegations that Caremark improperly rejected, denied or reduced the reimbursement of pharmacy charges. Continue reading

State Auditor: MassHealth Needs Better Checks On Income, Residency

Mass. state auditor Suzanne Bump

WBUR’s news staff reports on findings released today by state auditor Suzanne Bump. She found shortcomings in the state’s $12-billion MassHealth program, the government insurance for lower-income residents:

State auditor Suzanne Bump is auditing the MassHealth program, saying it lacks safety measures to verify applicants’ income, or that they live in Massachusetts.

The audit says MassHealth, which provides care to low-income residents, cost the state $6.5 million in 2010 alone by treating patients who may have lived outside Massachusetts. It also does not verify an applicant’s supplemental income, such as lottery winnings.

And State House News reports:

Income verification shortcomings in the state’s massive MassHealth program make it possible for ineligible applicants to receive health insurance benefits for a year before being removed from the program, according to an audit released Wednesday. Continue reading

Poor, Sick And Cut Off From Dental Care

By Dianne Finch
Guest Contributor

Mike Bush eats only one meal a day to avoid chewing (Photos: Dianne Finch)

Mike Bush is 45, unemployed and struggling with paranoid schizophrenia. But he has an even more pressing problem at the moment: lunch.

Bush’s teeth are so bad that he eats only one meal a day to avoid chewing.

“I shy away from meats and things. I told my dad that I’m running out of teeth to chew with. No big deal,” he said. “I’m probably going to end up with dentures.”

Bush, who lives in Bedford, Mass. started seeing a dentist three years ago for the first time in decades.

But his timing wasn’t ideal. In 2010, just after getting his initial dental exams and cleanings, MassHealth, the state’s program for low-income residents, cut its budget dramatically. Critical dental benefits were eliminated from the plan: fillings, crowns, root canals, and dentures were no longer covered. Extractions, for better or worse, were spared.

The problem isn’t isolated to Massachusetts. In states across the country, adult dental services provide an easy target for cash-strapped lawmakers looking for cuts, according to a 2011 report by the Institutes of Medicine, “Access to Oral Healthcare for Vulnerable and Underserved Populations.”

One reason, the report points out, is that Medicaid requires dental coverage for children, but not for adults. It referred to a February 2011 letter to states from the U.S. Department of Health and Human Services reminding them that Medicaid savings can be achieved via adult dental cuts.

“While some benefits, such as hospital and physician services, are required to be provided by State Medicaid programs, many services, such as prescription drugs, dental services, and speech therapy, are optional,” the HHS letter said.

So, many states are scaling back on the adult programs. Others are already moving to restore certain dental services after struggling with some unintended consequences due to earlier cuts.

Heading To The ER Instead Of The Dentist

For example, some states that track dental-related emergency room visits are seeing much higher costs. And physicians unable to treat dental problems are generally handing out opiate painkillers and antibiotics, according to Centers for Disease Control data cited in The New York Times.

Dental problems are sometimes perceived as less important, or somehow distinct, from overall wellness and good health, studies show.

But the 2011 IOM report advised governments and universities to integrate oral health into overall health programs in order to improve access to services and remove disparities.

“The enduring separation of oral health care from overall health care has marginalized issues related to oral health,” the report said.

An elderly woman on MassHealth exhibits the results of poor, erratic dental care over the years.

An aside: I know this from personal experience. A close relative who is mentally ill and on MassHealth has black front teeth due to multiple, untreated cavities and old fillings that are falling out. After waiting two years for a dental appointment, she recently had the two most painful teeth pulled, though they could have been saved with fillings. (She also has 40-year old fillings that need replacing, but has no disposable income to pay for treatment.)

Another close relative, an elderly woman, also on MassHealth, has been trying to get dentures for several years because she only has five teeth left. She can’t afford care, though, and today I’m taking her to my own dentist for an emergency appointment, paying out of pocket, because her teeth became so jagged they were stabbing her in the tongue. Continue reading

Sick (And Poor) In Massachusetts: Longer Waits, Less Satisfied Patients

(Harvard School of Public Health/WBUR/Blue Cross Blue Shield of Massachusetts Foundation/Robert Wood Johnson Foundation)

Brecah Bollinger, a 42-year-old mother of three in Quincy, requires a lot of medical treatment. But, she says, she often feels like a critical element is missing from her health care: the caring part.

Diagnosed with an immune system disorder, sarcoidosis, Bollinger has near-constant joint pain, trouble breathing, deafness in one ear and a slew of other symptoms that prevent her from holding a job, she says.

She’s on MassHealth, the state’s subsidized Medicaid program for low-income residents. But Bollinger says that as soon as she steps into the doctor’s office, she enters a world in which she feels inferior — rushed, ignored and discounted at each step. “I call it assembly-line health care,” she says. Doctors have abruptly stopped her from talking by putting a hand in her face, suggested she’s addicted to painkillers and left her alone in an exam room in the middle of a medical history, seemingly too busy to take her myriad symptoms seriously, she says. Although Bollinger reports that she was assigned a primary care doctor five years ago, she’s never seen her: that doctor’s schedule is always full. So Bollinger says she just takes whichever provider happens to be free.

“I’m treated horribly,” she says. “I want my doctor to be thorough even if it takes more than five minutes. Frankly, I’m embarrassed to be on MassHealth — they think, ‘Oh, you’re poor, you must be a drug addict.’ Or, like, ‘Your insurance doesn’t pay me enough to be thorough.’ ”

Despite nearly universal health insurance coverage in Massachusetts, which has clearly helped residents, mainly the poor, gain access to medical care, disparities persist.

Bollinger says she has a friend with renal cell cancer who is covered by private insurance and experiences health care in an entirely different, more humane manner. “She has Blue Cross and they treat her like a queen,” Bollinger says. “They pay for her transportation, and her primary care doctor, on days off, calls her just to check in.”

It’s tough enough being sick, but when you’re sick and poor, you’re far more likely to experience long waits and care that leaves you unsatisfied and feeling discriminated against because you’re on Medicaid or other public insurance.

In our poll, Sick in Massachusetts, we asked residents who said they had a serious illness, medical condition, injury or disability requiring a lot of medical care, or spent at least one night in the hospital within the last year about their experiences. We found that sick people with lower incomes (under $25,000) are significantly less likely than middle-income (from $25,000 to $74,999) and higher-income folks (over $75,000) to say they are very satisfied with their care. And more than one-fourth of the lower-income sick report that they were treated worse than others because of their insurance status, a significantly higher proportion than for middle-income (13%) and higher-income (2%) sick. Continue reading

Into The Abyss: A Freelancer (Fretfully) Prepares To Pay For Health Insurance

Amanda Art will soon start paying for health insurance....but how much?

By Amanda Art
WBUR

The form lay on my desk for weeks, untouched. I knew exactly why I didn’t want to fill it out: doing so would start the ball rolling toward a significant change in my health insurance – and how much I pay for it. However, these changes were coming whether I liked it or not, and ignoring the form meant my coverage would disappear altogether. With time running out, I gritted my teeth and grabbed a pen.

The focus of my procrastination: the eight-page MassHealth Eligibility Review Form. A short back-story: I moved to Massachusetts in 2008 after losing a job, and qualified for the state’s version of Medicaid after my unemployment insurance ended. In practical terms, being on MassHealth has meant I haven’t had to pay a monthly insurance premium or co-pays when I go to the doctor. Due to a chronic condition (that’s for another story), I take at least four medications a day, which currently cost $3.00 each per month. Continue reading

Since Recession, Nearly All Mass. Insurance Newcomers On Medicaid

Don’t miss today’s important story by WBUR’s Martha Bebinger about the recession’s effect on health insurance in post-reform Massachusetts. It’s here, and here’s the gist: “The latest numbers show that virtually all Massachusetts residents who have gained coverage since the landmark 2006 law passed are now in a government health care program.”

This wasn’t supposed to happen, Martha recalls. The early mantra of the state’s health reform was “shared responsibility,” meaning that individuals, employers and state government would all share the burden of getting more people insured.

But here’s my analogy: If Massachusetts is the country’s laboratory for health care reform, the recession has contaminated our test tubes, and skewed our results. Martha reports:

WBUR's Martha Bebinger

Many experts agree the recession has played an enormous role in this shift from private to public coverage. Since the coverage law passed in 2006, 411,000 more residents of Massachusetts have health insurance; it’s the largest insurance expansion in the country. In the first few years, the expansion was fairly evenly divided between private and public insurance. That’s no longer the case.According to Nancy Turnbull, an Associate Dean at the Harvard School of Public Health, “virtually everyone” of the Massachusetts residents who have received health care coverage with the implementation of the new law are enrolled in a public plan.

“It’s virtually everyone because the number of people who have employer coverage has gone down,” Turnbull said. “That’s not at all surprising, that’s happening all over the country.”

All this is very politically sensitive, Martha notes: “There’s concern these numbers will reinforce the view that Massachusetts, and by association, the national health reform law, is launching a government health care takeover.”

But it ain’t over till it’s over — that is, the recession is over. The Patrick administration tells Martha the very latest state numbers, still unpublished, will look better. And one more important point, from Harvard’s Nancy Turnbull: “The good effect of our law is that we have not had the large increases in the number of people without health coverage.”

Lawsuit Says MassHealth Violated Disabilities Act

Here’s the full report from Kyle Cheney of State House News Service:

The Disability Policy Consortium filed suit Tuesday against MassHealth, contending that the Medicaid agency that insures more than 1 million Bay State residents has failed provide disabled applicants with adequate communication options.

The suit, filed in U.S. District Court by the consortium and eight plaintiffs – four blind residents, two deaf residents and two with other disabilities – concludes that MassHealth violated the Americans with Disabilities Act by failing to provide Braille or electronic forms that can be filled out without assistance, failed to offer materials in American Sign Language, and that the agency generally makes it difficult to contact a live customer service representative.

Several plaintiffs – MassHealth members for decades – argue that their health care services were canceled or suspended as a result of their inability to fill out required paperwork and because of the agency’s inability to offer assistance, despite requests for interpreters, accessible forms or other forms of help.

“Defendants have committed multiple ongoing and continuous violations of the ADA and the Rehabilitation Act, and unless restrained from doing so, Defendants will continue to violate the ADA and the Rehabilitation Act. Said conduct, unless enjoined, will continue to inflict injuries for which Plaintiffs have no adequate remedy at law,” according to the suit. Continue reading

Tobacco Specialist Questions Study on Heart Attack Decline For MassHealth Patients

Liz Cooney raises some important concerns in her Boston Globe story on a new study that says the risk of being hospitalized for heart attacks was cut nearly in half among MassHealth participants who enrolled in the state’s comprehensive smoking cessation program.

The Department of Public Health sent out a news release yesterday about the study, and trumpeted the smoking cessation benefit, which includes access to nicotine patches and a prescription anti-smoking drug. The DPH also suggested that the 46% drop in heart attack risk was a direct benefit of the state’s health reform law. But Cooney quotes an expert discussing some of the study’s flaws:

Dr. Michael Siegel, a tobacco specialist at the Boston University School of Public Health who was not involved in the study, said the study’s methodology gave him pause. While there was clearly a drop in heart attacks among the people who used the stop-smoking program, there was no control group of other MassHealth members who did not participate. He said that makes it difficult to conclude that the decline in heart attacks is caused by the program itself rather than being a reflection of falling heart disease rates in general.

Siegel also said flat rates of respiratory illnesses were puzzling because asthma and pneumonia are among the first diseases to fade away when someone quits smoking.

Siegel’s third objection involves the gap between the actual heart attack rate — 8 percent — and the adjusted rate — 46 percent — arrived at after the researchers took into account such factors as other illnesses, including flu, and implementation of the state’s smoke-free workplace law. He said such a drastic difference makes him question the model the
researchers used. “I feel more work needs to be done,” he said.

Dental Misery: MassHealth Cuts Take Toll

Massachusetts led the way toward getting more people covered by health insurance, but recently it took a notable step in the other direction.

As of July 1, about 700,000 poor adults statewide lost their dental coverage through MassHealth, the public health insurance program, as a result of budget cuts. CommonHealth asked Christine Keeves of the advocacy group Health Care For All how the cuts were playing out.

Q:What are you seeing as a result?

A:  Health Care For All has a HelpLine that can answer general insurance questions, tell folks what free and lower-cost programs they may be eligible for, and help them to apply all in quick and easy telephone call. They have experienced a spike in calls now that the cut has been made. Our Helpline counselors have already collected stories from every corner of the state from MassHealth members who are in pain, unable to eat, sleep, or work because of dental pain, and who are getting sicker and sicker while they try to find care.

· A Worcester woman, pregnant and on disability, needs two root canals that she cannot get because the procedure is no longer covered, which is endangering the health of her and her unborn child.

· A Mattapan man who has had 8 extractions cannot get the dentures he needs not only to go on job interviews (which we all know is incredibly important, especially in the current economic climate), but also for such basic functions as eating and speaking.

· Our Helpline counselors are in the process of assisting a Springfield woman who is mentally ill and diabetic. She had to have all of her teeth pulled in June. In light of this cut she is unable to get dentures. Her doctor warns that she will die without the dentures. Continue reading