Friday, August 31, 2012

Medicaid, TennCare, Birth Control and Welfare Babies

So I'm going to bypass posting part two of my TennCare rant for right now, to post something I find a little more.. controversial.

TennCare pharmacy benefits are run by SXC, which the state contracts.(You can read more about this HERE) Not the health insurance company you get through tenncare, SXC manages ALL TennCare prescription benefits for Tennessee.

I have touched before on the limits of TennCare prescription benefits, at 5 a month and how this really affects most disabled people. 
Well, in doing some research to try to get some of my necessary medications covered (which so far hasn't happened, since no one can figure out what I'm talking about) I have uncovered some things.

  1. Per health care reform law, TennCare must cover birth control services and birth control with a 0$ co-pay.
  2. Birth control counts against your 5 monthly prescriptions and according to SXC representatives, Walgreens pharmacists and my OB/GYN is in no way attestable or in layman's terms able to become 'exempt' from counting towards your prescription limit.
  3. That women on TennCare can have ONE pap/std test a year, unless they exhibit symptoms.
  4. That there is no readily published numbers on how many pregnancies happen by a recipent of TennCare.
     5.That there are no readily published numbers (or studies) on how much TennCare pays each quarter       (or yearly for that matter) on maternity services, or pregnancy prevention. 

Well, this irritates me. One of the categories for TennCare eligibility (within income restrictions) is being pregnant.
Ok, well. Of course you have to already BE pregnant in order to get TennCare if you do not fall into another category (like disabled) so of course that already reduces the numbers of pregnant on TennCare people.
So for the sake of numbers, lets count TANF recipients too, (Cash assistance, aka welfare cash)

In Tennessee in 2008 (yes its a slightly outdated fact sheet, I can't find a newer one) there were over 144,000 TANF recipents, which is actually less than in 2007 due to cuts in eligibility.

So, lets say 144,000 TANF recipients (which are all women here in TN) plus the 1,000,000 or so disabled people in Tennessee ALL qualified for TennCare, regardless of pregnancy status.(For the sake of numbers, I will say 200,000 receive disability and are of child bearing age with tenncare, which is a far cry from what is likely true)

So 344,000 people eligible for TennCare. OK, well. The average birth control prescription, is 25$.
So, assuming for the sake of numbers that all females are on and prescribed the pill, at 25$ a month. Well the state won't pay that much, so it will be more like 14$, because they have contracts. OK. So 14$ *344,000 people.equals 4,816,000$. Per month. So times that by twelve, you get $57,790,000 (Now many people go off welfare and lose their eligibility but for numbers sake..)

Its expensive, yes.
For other birth control options, theres the shot (about 30$ for 3 months) or an IUD (about 300$ for FIVE YEARS) but I wont go into that, for the sake of simplicity

The average maternity pay out is $3,500 for basic care (not including NICU, preemie care or high risk) in Tennessee. So again for the sake of numbers lets say 100,000 of those 350,000 people that meet our critera get pregnant. Thats $350,000,000. 

So birth control preventatives - $57.75 million per year vs Maternity care for 1/3 the population that would be taking the birth control if covered by TennCare at $350,000,000.

Well, thats only a difference of $292,210,000. Thats a nice chunk of change.

Well.. what numbers don't show you is that since mom qualified for TANF/Medicaid, now her kid/kids do too.
So.. that's another 100,000 children TENNESSEE needs to cover. (TennCare covers about 1.3 million pregnant women, children and disabled people each year)

So.. for the sake of numbers.. lets say each kid is very healthy and only needs minimal care after birth (assuming newborn care in hospital is under moms maternity spending)

So 100,000 children times about 3000$ in regular yearly health care, including dental, vision, well child check ups, prescriptions and vaccinations, is $300,000,000, assuming the child is not disabled or needs ANYTHING special.

So lets do a quick breakdown of the numbers one last time

Birth Control for 344,000 people of child bearing age (assuming the pill only) =$ 57,790,000 YEARLY.
Maternity Care for 100,000 women who get pregnant while eligible for TennCare (assuming basics and singleton births only) = $350,000,000, yearly.
Basic medical care for children born on TennCare now qualifying for TennCare (assuming 100,000 babies) =$350,000,000 yearly.

So $700,000,000 a year in maternity +infant child costs (for child born through TennCare)
                               = $642,210,000

Well, I think a little more than half a billion dollars is pretty signifigant, don't you?

Then theres the cost to the tax payer (ahem, state) on increased assistance for families of those children. Lets assume only 80% suck up their pride and accept food stamps. Well, thats 1200$ additionally a year for the first four years or so (For numbers, many people do get off assistance entirely).
1200*80,000 people-$96,000,000 yearly.
Then lets assume that 40 percent take housing assistance (which is god awful to live in, much less even apply to the waiting list for, its nearly impossible to get)
So well say average assistance amount for that is 600$ per month per family
$600*12*40,000= $288,000,000 yearly.
Lets assume that 70% of new moms take WIC with baby formula for the first year (based on national breast feeding statistics)
So not including the average food benefit, lets say WIC spends about 200$ a month in formula and baby foods per child for the first year of life.
So, 200*12*70,000=$168,000,000.

So for one year for these 100,000 preventable births, in addition to the $642,210,000, add in $552,000,000 in first year costs, thats $1,194,210,000.

Or in simple terms, 1.2 BILLION dollars per year, on completely preventable births, in the state of Tennessee.

Then there's things like transport costs (Medicaid picks this up I believe) and additional things I can't possibly think of, not including cash assistance, DNA testing, child support orders/enforcement, custody, courts and CHILD CARE. I am NOT counting in child care assistance, as that figure just blows my mind. (Average subsidy per child can be between 300-1000$ A MONTH)

Considering Tennessee has about a 16% below poverty level rate (this is an estimate link) this doesn't really surprise me, but makes Tennessee the third poorest state in the United States.

So my question, dear tax payers, legislators and beaurocrats, why on earth are you supporting the perpetuation of poverty and the burden of the tax payer dime, by denying something as basic as birth control?

Feel free to leave your opinion in comments, or via email.


Monday, August 20, 2012

TennCare (Medicaid) and The Taxpayer Money (WASTE) Part One

So I see a lot of people whining about 'Obamacare' and how its going to bankrupt our country, like Medicaid (insurance for the poor and disabled) and Medicare( for the disabled and elderly)  already have.

I am slightly inclined to agree.
I am a liberal independent. I do not side entirely with either democrats or republicans,  I am pro legalization of marijuana (especially for medical reasons) pro universal health care and pro choice. I am against immigration amnesty and fining people for not having health insurance.

Let me tell you about a few things I have noticed as a recipient of Medicaid. 
As a disabled person actively receiving social security benefits, I am qualify for Medical Assistance, which I do utilize.

Here in Tennessee its called TennCare. Tenncare is a joint funded 'project' by the state and Feds. 

TennCare is one of the WORST Medicaid providers in the country.

This is what my benefits look like (which is standard)

5 Presciptions a month, unless on the 'exempt list' (Which comprises of mostly retrovirals for AIDS drugs) 3 generic and 2 Brand Name, with a 3$ copay. Certain medicines such as Benzodiazapines, Pain Killers, Controlled Substances (narcotics usually) and certain sleeping pills, amongst others are NOT covered.

Weight Management program IF qualified (must be over weight or have a comorbitiy like diabetes, high blood pressure.. so on) which can include, nutrition classes, a gym membership to the YMCA, counseling, and weight loss surgery.

12 visits to a Primary Doctor a year, unless you have a medical exemption (I do)

Limited in-patient hospital care

No dental
No vision
No chiropractic care

Pre-authorization required for most testing, such as CT scans, MRI's, and so on. Basics like blood work, EKGs and xrays are usually covered with just doctors orders.

Emergency Room Care

Thats about it. Now that seems like A LOT to someone without any insurance, and by all means it is.

Personally, I am grateful I have any insurance at all.

However, I have MANY MANY MANY issues with TennCare.

First and foremost the prescription benefit limit, as run by SXC. 

I am on disability. Don't you think I need more than 5 prescriptions a month? I usually blow through that in antibiotics a month. Yes, they have something called an exemption waiver, where a doctor tells the insurance company why that medicine is medically necessary and should not be counted towards your prescription limit. Out of the 23 current practitioners that I have, not a single one knows what I am talking about or how to do this. The insurance company insists that the doctors should and will not tell me how to have them go about this.

So each month, I regularly choose between antibiotics, heart medications, lung medications (asthma, allergies, so on) kidney medications, skin creams (usually for skin infections) auto immune suppressants, allergy medicines (like an EpiPen, or a cream for hives) GI drugs (for my stomach/intestinal issues) ear medicines (for whatever) and birth control.

Usually the antibiotics win. Sometimes a mental health medication may win a spot, but rarely.
I was told by the pharmacy and by SXC that they do not consider an EpiPen to be an emergency drug and thus it counts towards my benefit.
So if I got stung by a bee, used my EpiPen (and saved my life) received medical care and a prescription for a new one, and I had already used my 5 for the month (or 2 brand names) then I could NOT get another life saving EpiPen until the next month.

Thats some bullshit.

I find it ludicrous that not a single practitioner knows how to fill out these forms, or jump through the right hoops, and I completely believe each practitioner when they say they cant figure out HOW to do them, or that they ALWAYS get denied.

Second, perhaps I was more spoiled by Medicaid in the north (Access, in Pennsylvania, where I hail from) where I had somewhat limited dental and limited vision care, as well as unlimited prescriptions each month. (Some did require prior auths, which were easy to get) However, I find that as a disabled person, that Access actually met my needs 98% of the time, versus TennCare which meets them about 40%, if that.

In Pennsylvania (not saying they are perfect, they are not) there were different 'classes' of Medicaid, and Medicaid eligibility, just as there are here. You could be:
On cash assistance (welfare, TANF)
Under 21
or other, which usually meant waiting for disability
OR a cancer patient 

Each category usually had its own rules and benefits. 
I can only really speak to unider 21 and disabled, since I have received both.

Medicaid for disability is supposed to be life sustaining, health sustaining. They put these lovely little provisions in 'appeals' (Ill get to that later) where if it could cause damage, death or hospitalization, its considered an emergency.

Well, usually if you are on disability a lack of care or medication could cause any of the above to happen.
Benefits in all states are far better for CHILDREN on Medicaid. Usually those on disability have something similar to that, as again, its expected to be health/life sustaining.
Not so here in great old Tennessee.

I get the SAME exact insurance pregnant moms get, welfare recipents get and so on.

Mom who lost her job or had to flee domestic violence and lives on Cash Assistance, probably does not need to see 23 doctors and take 18 prescriptions a month.

I do. I am not alone.

So, instead of say, TennCare covering a 2x a year dental cleaning at 40$ a piece, I dont get it done. In turn I get abcesses and infections and need antibiotics, at about 40$ a pop per antibiotic. Surgical removal of the abcess is quite expensive I'm sure, however I dont have the money to get that done so I dont know.

Another dental example: My wisdom teeth are coming in, at nearly 25 years old. (I turn 25 on Wednesday)
My jawbone is currently exposed, and will likely cause all kinds of problems, from infections of the bone to abcesses and distorment of my jaw and teeth.

So instead of paying 300$ to remove my two wisdom teeth (Medicaid pays WAY WAY WAY less than standard private insurance, in case you are wondering why my figures are so low) Medicaid will pay to have my jaw surgically fixed, and bone removed, in addition to the antibiotics, hospitalization and care required, as well as prescriptions, at about 30-40,000.

That makes sense right?

Heres an example:

ABout a month ago I started randomly passing out. I was seeing colors, had a headache to bad I wanted to die, was vomiting non stop, slurring my speech and had lost my appetite and had severe sensory hallucinations (smelling, tasting things that were not there)

I went to my primary who suspected a migraine, but wanted to make sure by ordering a head CT and called in a migraine prescription.  Well, dont you know I reached my benefit limit, so no migraine medicine.
At 6 pm on a friday I had no other choice.. I wanted to die. So after I passed out, I went to the local ER.

That bill was probably about $2000 that the state PAID.

Well the ER here sucks and they gave me more prescriptions I couldn't fill.. so I had to go back when I passed out again. 

Probably another 3k in work done, at the er.

Well three days later it still hadnt gone away, I had just stopped going to the ER, and I went one last time, this time in Nashville. That probably cost about 300$, since they did NOTHING.

So, instead of covering a 50$ prescription that *might* have solve the issue, thy just paid at minimum $6000 for medical care for me, and still didnt treat or solve the problem.

it took two weeks and five antibiotic prescriptions (and a bag of antibiotics in the ER the second time) to get rid of that. I still dont know what caused it.

They denied the head CT saying it was medically unnecessary. So... those symptoms that scream STROKE or TUMOR mean nothing, I guess.

This is just one example.
This post is already getting too long so I will have to do a part 2.