Medicare and How the Game is Played

so, I am now on Medicare with a “Plan F” supplement and a private policy which actually includes Part D.

I have been using sleeping pills for 15 years.
I have had osteoarthritis for 10 years.
Kidney failure for 7 years

Since going from a nice PPO to this Medicare-based Frankenpolicy, I seem to be getting more attention from the U of Cal medical group.

All of a sudden, I get referrals to:
MRI
PT
2 obscure Nephrology tests I’ve never heard of
Polysomngraph (sleep) (which, of course finds that I simply MUST have a CPAP*)

I am just suspicious enough to think that the group has decided that the way to compensate for the lower payments Medicare provides, is to ding them for more procedures.

Anyone else find a sudden absolute need for testing/equipment once they switched to Medicare?

    • my problem is getting to sleep, not staying asleep. Adding a mask and a machine to fiddle with is not likely to help the onset of sleep. If I was waking or not dreaming, I’d be more amenable to CPAP.

Medicare does pay for chronic kidney disease, but now they are interested in reimbursing for ‘good outcomes,’ and not on the old ‘fee-for-service’ basis, so that may explain the additional tests.

Health care coverage and payments are undergoing big changes. You may be part of a ‘managed care’ plan for those with ‘co-morbid conditions’ in an effort to keep you healthier for longer.

I do love the term “Co-Morbid”. So absolutely perfect!

I remember the term “managed care” from my mother’s terminal nursing home experience - she had more tolerance for bullshit pencil-pushers than I.

So far the “management” has been “cut his opioids (DEA) and then put him on PT to ensure more pain than he can control”.

And the longer I last under these conditions, the better?

I guess the definition of “good outcome” varies.

I think it is called “The Chronic Kidney Disease Initiative.”

I can’t find much that is not an abstract, but here is one I found:

Kidney disease is the ninth leading cause of death in the United States. In 2000, more than 26 million adults were estimated to have chronic kidney disease (CKD), placing them at risk of progressing to kidney failure. The number of new cases of kidney failure treated by using dialysis or transplantation in the United States has more than doubled since 1990, and it is expected to continue to increase with the aging of the population and the increasing prevalence of such risk factors as diabetes. In recognition of this problem, Congress passed legislation to build capacity and infrastructure at the Centers for Disease Control and Prevention (CDC) for a public health approach to CKD. This Kidney Disease Initiative at the CDC includes surveillance, epidemiology, state-based demonstration projects, and economic studies. The objectives, in collaboration with partners, are to assess and monitor the burden of CKD in the United States, determine its risk factors and rates of preventive practices, develop methods to identify and monitor populations at risk of developing CKD, document the costs of kidney disease, and develop models to help predict the progression of this disease and test the cost-effectiveness of various public health strategies for preventing CKD.

Thanks for the research!

I was able to stay at stage III by watching diet (I miss my Pepsi!), but am slipping rather quickly.

What I can tell of the scheduled tests, they are looking in urine for stuff that doesn’t belong in urine - don’t know it this is the prize for reaching IV or just another set of numbers for the MD (who is doing a Fellowship) to study.

So far, no questionnaires from nephrology.

And at least no product brochures for dialysis machines.

Yes, there was also a big change to reduce opioid availability (hydrocodone) last fall.

Things are changing very quickly.

In the past, we (Americans) have focused on fee-for-service disease care, and the shift now is to disease prevention and management.

American spend more on health care than any other country. Something like 19% of our GDP, maybe $13,000.00 a year per person, is spent on health care and our outcomes are poor and worse than one would expect for the amount of money Americans spend. (I am using my memory for the numbers. I may not recall them exactly.)

Many insurance companies (and the government) are now switching to an outcomes-based payment system. The real truth is that we’ve been used to spending a lot of money on health care but not have bothered to evaluate if the money was well spent. Add the aging baby boomers who are just about now reaching Medicare age, and that is a recipe for expensive disasters.

I hope you get the less expensive but better quality care you need. I don’t know what stage your disease is in right now, but the goal will be to delay or eliminate the progression, which will be good for everyone (especially you).

The four big ticket items are cost, quality, outcomes (research) and access.

Good gawd, the “Chronic Kidney Disease Initiative” is another “Mandated by Congress” health initiatives.

This promises to be quite a ride.

If only my co-morbid was something that also showed up on the metabolic panel, it could get real bizarre.

Next CA ballot initiative - “Medical LSD” !

It wasn’t just that the hydrocodone-containing meds got upped to Sch II (thereby eliminating how many MD’s who will prescribe it)*?
There was a blanket alarm from DEA about “3 TIMES too many opioids!!!”. Not only did I have to sign a bullshit “Controlled Substance Agreement” promising not to sell my drugs, but I got an unannounced “pee in the bottle test” to make sure I was taking them.

After my dosage was cut from 45 to 15.

    • Docs who wouldn’t prescribe Sch II could prescribe Sch III (vicodin, percowhatever) and get a real drug. Dentists come to mind - how many will now start messing with the triplicate 'script form required for Sch II?

Just for jiggles - straight hydrocodone is not commercially available in the US - you cannot write a prescription for hydrocodone - if you want to prescribe it, you use one of the used-to-be-Sch II’s. Oh yes - and people with kidney disease are not supposed to take NSAIDs.

I don’t know the particulars of your previous PPO but many of them simply deny such things as CAT scans or MRIs outright, now that you are on traditional Medicare the doctors are able to get authorization for tests they have been wanting to do for years.

The wife has Sleep apnea. I know this, she knows this, the doc knows this, AND EVERYONE WITHIN A FIVE MILE CIRCLE knows this. After a decade plus, it is time for a new machine. But wait, Medicare hork up a new cpap machine without a 2400.00 test. Wife does this and wonders how anyone can sleep wired up like the Borg. And we wait. Weeks later, we were told that the test she took to determine the correct settings for the cpap was the wrong test–they wanted one to determine if she HAD apnea, since they could not find the record for the test back when there was still smoke rising from ground zero. Back in for another Sleep(less) Study. More time waiting for forms to move about. We are at 4800.00 for this insanity.

Of course, the kicker is the machine is 900.00 on Amazon…

The PPO was a very nice Blue Shield of CA - it had no problem with MRI, X-Ray, some incredibly expensive cardiac test involving synthetic hormone (test, inject, wait exactly 60 minutes, test again).
About a month after getting it, I ran up a $54K visit to ER/ICU, transfusions, EKG, and more.
Not a peep.
And they paid full price.
Medicare doesn’t.

For the “Oh my GOD - it is a miracle you aren’t dead without a CPAP” B.S. - the test was 3/19 and have heard nothing except the PCP commenting on how my score was off the chart.
It is interesting that they don’t seem to think it necessary unless Medicare pays for it - no mention of possible out-of-pocket purchase, no mention of a lease arrangement.

One thing about why your wife may need yet another test - I digging through the data, I found a number for which the diagnostic level has always been .3. According to this page, Medicare has upped it to .4 before they will pay. Maybe they need to get her on record at .4 (whatever).
It smells like “Bill Medicare for CPAP and associated testing and support” has become a thing - some huge percentage uptick in a very short time.
I am seeing UCD Medical group. The sleep test was done by something called “California Sleep Solutions” - which got the referral, is located on the UCD campus, and has very nice CPAP machines permanently installed in the exam rooms.
The report I got does not show the sensors - just the “interpreted” results. No record of eye movement, just a line which is labelled “REM Stage”.

When asked about the relationship between the CSS and UCD, the response was “there is so much work on the UCD sleep lab that we now handle the initial testing”.

Smells like a conveyor belt operation.

“Welcome to CSS!” “Thank you for your night of non-sleep, here’s your CPAP*”.

    • as soon as Medicare pays us a few thousand.