Friday, March 9, 2018

MedImpact Healthcare Systems, Inc. – Clozapine Determination – Discovery for CMS – By Keith E Torkelson, MS (2017-2018)


Name of Post
MedImpact Healthcare Systems, Inc. – Clozapine Determination – Discovery for CMS – By Keith E Torkelson, MS (2017-2018)
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Google Plus Information
MedImpact Cost Containment Study – Applied Lived Experience – Rimal B Bera MD and Clozapine (Torkelson, 2018)
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Dr. Rimal B Bera
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Memoriam
Mark 2017-2018
In this report we honor those Universal Care Brand New Day members that Died Too Young (DTY).  Here is a partial list of our associates Killed In Action (KIA) or Missing In Action (MIA): Mark, Dug, Lee, Ricky, Devon, and Trig.
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[INSERT PHOTOS OF DUG AND MARK]
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"Dug"
Member Who Died Too Young
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Mark - Died within a Year of this Photo
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MSG
"Scared Rabbit Productions"
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Abstract – Executive Summary – Essential Medication Denied
On February 15, 2018 we were pondering the renewal of our prescriptions: Clozapine, Lorazepam [SPELLED], Atorvastatin [SPELLED], and Lithium.  Clozapine is not to be confused with Klonopin [SPELLED].  Before our monthly call to our pharmacy, Gilbert Drugs, we said to ourselves this should go seamlessly.  It has not been seamless!  MedImpact a Pharmacy Benefit Manager or PBM audited our medications as they did last year (2017) around January.  The medication of interest is our life-sustaining Clozapine.  Last year after much work we were able to get an authorization to continue on our Clozapine as we have since 2012.  This year without any fore notice they refused to approve our Clozapine.  We did not find out with an Advance Letter as we had in 2017.  We found out when the Pharmacy (Gilbert Drugs) refused to fill this essential medication. 
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Alternative – Out of Medication - Hospitalization
We came one day away from having to admit ourselves to the Behavioral Health Ward (BHW) to protect us until with could get stabilized on Clozapine and sent home with a thirty (30) day supply. This has been truly a crisis for us.  At one point we “Panicked” when the nasty pharmacist said no way no Clozapine.  We barely pulled through relying on our Clozapine Net 2017.  Yesterday, February 26, 2018, we received our monthly medication accounting from our insurer (Brand New Day).  The statement for January 2018 indicates that Brand New Day doesn’t even pay for a part of our Clozapine.  This process is called a Determination. 
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“Denial” to Approve - Quality Outcome Score (QOS)
MedImpact the Determining body offers up promises about their services.  Last year we gave them a 61.5% for their QOS.  This year we grade them for Quality a 19.2%.  In short for this year (2018) so far we are not Satisfied with MedImpact’s services and supports.  It is hard to believe they represent the Consumer’s interests in any fashion.  It looks like the costs outweigh the benefits in our case.  In addition, MedImpact increases our chance for catastrophic loss including checking into the hospital in order to resume safely our Clozapine Regimen.

Person-Place-Thing
The person who takes Clozapine is Keith T.  He lives in Santa Ana California.  His insurer is Universal Care Brand New Day (BND).  Brand New Day has offices in Garden Grove California.  Keith’s lab work that is associated with Clozapine is performed by Central City Community Health Center (CCCHC).  CCCHC has offices in Garden Grove California on the second floor of the facility that BND maintains the first floor.  BND and CCCHC are co-located.  This report is a product of Mentalation Solution Group (MSG) with offices in Tustin California.

20180225-SUN: Update – Progress Note
At 317pm today an automated system from MedImpact called us on our cell phone.  The Automated Voice announced: “Your prior authorization for Clozapine has been denied”.

20180308-TH: Update – Bera’s Position – Unless we follow up directly the letter below will be our last correspondence about this 2018 Clozapine Determination issue.  It looks like our new Behavioral Health Doctor (BHD) Rimal B Bera (RBB) will not support us with our preferred treatment.  What RBB is implying is that our previous BHDs in managing Clozapine are wrong.  The chronological order for our Clozapine related BHDs is: Singh, Inglis, Vu, Daniels (Made an error), and Bum Soo Lee.
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[INSERT LAST LETTER IN SERIES - BERA]

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Appeal Related Letter
Note we did not file an Appeal


20180309-F: Dear Dr. Bera,
It looks like in the letter that you do not agree with the chain of Psychiatrists that came before you.  It took more than ten years to get our primary psychotropic medication “Right”.  Incidentally, we did not submit and appeal.  It looks like in the letter you deny us of what we need without proposing and viable alternative.  If you would have asked us in our initial Medication Management Appointment (January 3, 2018) we were ready to discuss our medications with you.  We were nearing the end of this report.  All along the way we were downplaying your part.  We are nearing a “Fix” on our own.  Then boom you jump in supporting the “Denial”.
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Who are We? – MSG Origins
We are Mentalation Solutions Group (MSG).  Our records indicate that we founded ourselves on January 4, 2011.  In the process of foundations we defined some of the products we would like to deliver.  We also addressed some of our business tasks such as selecting a name.  In our 20110104 documents we indicated that we here at MSG would like to engage in Quality Assurance.  For us this report is product out of our External Quality Review (EQR) Division.  Our principal is Keith E Torkelson, MS.  He serves a dual role as consumer and provider. Universal Care Brand New Day is the insurer for Keith.  Keith is the subject in this report.  The primary object for this report is the Brand New Day contractor MedImpact.
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What is MedImpact?
FYI - FAQ - MedImpact | Member Website
What is MedImpact?
“MedImpact is your PBM. A pharmacy benefit manager (PBM) administer is the pharmacy portion of your healthcare benefits, as defined by your plan sponsor. We work with your plan sponsor and your network pharmacies to provide timely, important information about your medicine, including how to take it, potential side effects, any lower-cost drug options, and more.”
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Integration
Brand New Day – Pharmacy – Behavioral Health Doctor - MedImpact
In order to deliver on our monthly Clozapine prescription is requires the integrated efforts of many agencies some we are familiar with and others not.  The Clozapine delivery agencies are:  our Behavioral Health Doctor (BHD), Central City Community Health Center for the monthly lab work (CBC), Quest Diagnostics Labs for the monthly lab testing, the Clozapine Registry, and our pharmacy Gilbert Drugs.  The principle reason the monthly Clozapine process runs smoothly is MSG.  Last year a PBM Med Impact (MedImpact) stepped in saying our Clozapine would not be paid for as prescribed.  The team of agencies above stepped up and argued in our favor.  Our Clozapine for the remainder of 2017 would be paid.  This promoted our health for 2017.  This report addresses our Clozapine for the remainder of 2018.  Last year MedImpact gave about one month reaction time.  This year MedImpact gave us one day.  Since the denial of our life-sustaining Clozapine prescription has risk gaps on two occasions now.
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Medicare
Medicare is our base insurer.  Medicare has several Parts.  Overall we rely on Parts A/B/D.  In good times we rely only on Parts B & D.  This is a Part D issue that might escalate into a Part A.
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FYI - Medicare Parts A/B/C/D
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Again, we carry Medicare as our base insurer.  Brand New Day HMO is what we buy to deliver on Medicare.  Medicare has several parts.  Part D applies to the MedImpact Determination we are addressing here.
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FYI
Medicare Part A - Hospital Coverage
Medicare Part B - Your Medical Coverage
Medicare Part D - Your Prescription Drug Plan
Medicare Other Parts
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Aside - JMB’s Take – Vignette – Old as Dirt
Keith T. the consumer here has an aunt (JMB) who is 92 years old and still independent.  We enlisted her to review some of this material.  She could not make sense of it.  We hope that our readers can make sense of this report.  Yet, JMB does understand what it means to be “Denied” medication.  As you might imagine daily JMB is on between 6-12 medications.  Some of these medications help her live.  Without them her condition might quickly escalate as Life Threatening.  JMB goes to one of her doctors and he prescribes a very expensive and essential new medication that is not on her Formulary.  When the doctor’s office calls for approval she is “Denied”.  This ProActive MD acting in her best interest himself calls Determinations stating if you don’t give approval now I will admit her to the hospital and you will be paying for a Part A when we could have solved it as a Part D.  JMB may like this section better this time around because it will prove to her we listen to what she talks about when we meet Face-To-Face (F2F).
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[FIGURE INSERT DENIAL LETTER]
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Denial Over Quantity Limit


Denial Appeal Information
Note - We did not file an Appeal
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Satisfaction with MedImpact
If you stick it out by reading more or all of this paper, you will see that this is primarily a Consumer Satisfaction Report (CSR).
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#BFF = Big Fat Foot
If our Clozapine continuity is broken this year it is likely the Big Fat Foot will step in.  Having the Big Fat Foot looming about is not a good thing.  Historically, he delivers extra cost and catastrophic loss.  The BFF is a Thing Greater Than Us (TGTU).  For us when someone we love has a Heart Attack in their sleep and dies we blame the BFF.  The BFF is not to be confused with a Girl’s Best Friend.
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Solicitation Dilemma
[COPY OVER]
20180306-TU: Updated Solicitation Dilemma
For MedImpact Report
We here at MSG have been writing reports about the psychosocial aspect in Health & Human Services since 2009.  We find that if an Agency does not solicit our findings they lack the resources to consider them in depth.  Our current unsolicited report addresses the agency MedImpact and the topic Medication Determination.  One of the reasons we here at MSG continue to publish unsolicited reports is that they help us appreciate where we are and how far we have come for setting things Right.  We have sent some prior complaints to Centers for Medicare & Medicaid Services (CMS) who does solicit input yet we are taking a non-CMS mediated route with this Reactive Disappointment.
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Reminder – Mistakes Can Cost Us (Bera)
It is hard to believe that after being served by Brand New Day (BND) since July of 2012 that we would have an issue with our most important medication Clozapine.  In order to guarantee continuity in our Clozapine for February 2018 we were considering going to check ourselves into the Psych Ward at UC Irvine (UCI) Medical Center were rumor has it our new Behavioral Health Doctor (BHD) Rimal B Bera has hours.  We investigated a bit and found MedImpact to be the problematic link in this instance of Inappropriate Service.  Then we get the letter that indicated Dr. Bera weighed in.  He is how added to our list of those we served us inappropriately.  We had high hopes for Dr. Bera when we considered his background.  We were going to overlook that when we met him for our first appointment (January 3, 2018) her only had three medications to get right: Clozapine, Lorazepam, and Lithium.  He made an error by failing to prescribe Lorazepam.  That would make his Medication Management Error Rate (MMER) thirty-three (33) percent.
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BND V GBDP
When we first began Advocating via the Internet we published a string of papers associated with what we call the Graduate By Death Program (GBDP).  We did this because we wished to cause little harm (Harm Reduction Policy).  Brand New Day (BND) is our model GBDP.  Believe us there are many GBDPs in our community.
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Bottom Up Method (BUM)
MSG’s editor is none other than Keith himself.  Sometimes Keith goes by the penname Buster D Right.  On the last pass reviewing the text Keith uses the Bottom Up Method.  We are thinking of calling this method the Bottom Up Technique or BUT.
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Table V Matrix Defined (Policy and Procedure – PNP)
Our tables tend to be non-numerical.  In previous reports we did not formally distinguish between tables and matrices.  In general a matrix is a type of table.  Our matrices contain a good deal of numerical entries.  Our matrices include more than one column of numbers.  The date column counts as a column of numbers.  We do not include photographs in the list below.  If it is not labeled a Matrix or Table it is a non-photographic Figure.
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List of Tables – Matrices – Figures
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Community Partners X 10
Last Letter in Series - BERA
Denial Letter
Table - Acronyms - Brief
Matrix - Key Results First Method (KRFM) – Satisfaction
RX Statements
Clozapine Prescription for Keith Edward Torkelson, MS
Table – Prescription Share of Cost Distribution - Clozapine
RX Statement – January 2018
RX Records for Another Consumer
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Table – Coverage Determination - Clozapine Solutions (2017)
Table - Report Matrix - Summary Steps (MedImpact) – Satisfaction Checklist – MedImpact
Table - Results – Gilbert Pharmacy & MedImpact (2017 & 2018)
Table - Program Evaluation Program (PEP) Outcome Indicators
Table - Sharing Schedule – Advocacy & Alternatives
Table - Elements for Continuing Education Units (CEU)
Matrix - Results - How is it a Crisis - What Crisis?
Matrix - Results – Quick Score Method - Assessment for MedImpact Determination Process Challenges
Table - Key Event Logger (KEL) – Clozapine Determination 2017
Table – Qualities About This Intervention (2018)
Matrix - Comparative Clozapine Transaction Summary
Table - Subjective Distress as Measured By – About Determination 2018
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Clozapine Determination 2017
Table - Figures – Records – 2017 Determination
Table - TimeSpent - Scanning Efforts (Applied Materials and Method)
TransActor Transaction Summary (Counting Transactions) 2017 and New Incidence 2018
Table - 2018 Coping Time Line > Step Summary
Table - Qualities to End This Crisis (CIM)
Metadata – Determination – MedImpact 2017
Table – Documentation – MedImpact Clozapine Determination 2017
Matrix - Safety Net Comparisons – Context Medication Determinations – Balanced Scorecard
Table - Charter Information
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Table - Acronyms - Brief

Table – Acronyms – Last Updated: 20180218-SUN:
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Dedication
This study is dedicated to our friends that were refused the medication that they had grown accustomed to and required to remain fit and free.
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Matrix - Key Results First Method (KRFM) – Satisfaction
Rate Your Pharmacy Benefit Manager (PBM) - MedImpact
MedImpact Promises
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##
Promise
PBM 2017
PBM 2018
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01
Effective Management
0.5
0.0
Lower Cost
1.0
0.0
Better Care
0.0
0.0
Client Alignment
0.5
0.0
05
Lower-net-cost
1.0
0.5

Medically Appropriated Drugs
1.0
0.5
Good Value
0.5
0.0
High Quality Service
0.5
0.0
Client Satisfaction
0.5
0.0
10
Flexible Solutions
0.5
0.0

Member-Centric
0.5
0.5
Timely Information
0.5
0.0
13
Important Information
1.0
1.0

Quality Outcome Score
[MEASURE OF SATISFACTION]
8.0/1
61.5%
2.5/13
19.2%

Matrix –Rate Your PBM – MedImpact Promise Assessment: Last Reviewed: 20180309-F:

Value of Determination
Our evaluation indicates we are less satisfied with MedImpact this year (2018) than last year (2017).  As we plan to demonstrate the benefits here fall short of the costs for this MedImpact mediated Determination.
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[INSERT RX STATEMENTS]
Sample of Heavy Medication User
Sample of Our Medication Usage


Summary for One of Our Peers
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Summary for One of Our Peers
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Us
By Years End Other Payments for Clozapine Would Come out to about $1300.00
Note our some odd $1500.00 per year of Medication
Appears to be more effective the our Peers $21000.00 per year
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Who Do MedImpact Represent?
We did a little bit of research into MedImpact, its’ history, and services.  Online they indicate that they may be helping consumers such as us.  We think that there primary service is cost containment for Brand New Day and/or Medicare about medications.  If you look at some of our data in “Your Monthly Prescription Drug Summary” there really is not much to save about juggling our Clozapine Prescriptions.  In this instance MedImpact has not helped us out much other than offering us a huge distraction that cuts into the time we spend on non-behavioral health treatment plans such as: Dental, Dermatology, and Primary Care.
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For January 2018
Figure – Irony – How it looks when it is Right
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Figure – Clozapine Prescription for Keith Edward Torkelson, MS
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Table – Prescription Share of Cost Distribution - Clozapine
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Entity
Clozapine
Amt Assumed
Note
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Your Paid - The Consumer
$1.25
Plan Paid - The Insurer
$0.00
Assume Brand New Day
Other Payments - Extra Help
$103.35
Paid by Extra Help
This may be what MedImpact is targeting
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Table – Share of Medication Cost (Clozapine) – Using January 2018 BND Medication Statement
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[INSERT IMAGE OF RX STATEMENT – JANUARY 2018]
[PULL ANOTHER EXAMPLE MIKE-O]
A Second Look
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HIE-Health Information Exchange
MSG’s Principal Keith T volunteered for nearly ten (10) years with the Health Care Agency of Orange County California (OCHCA).  One of his posts was as the Consumer Representative on the Technology Advisory Committee (TAC).  He participated in several Health Information Exchanges (HIEs) outside of the OCHCA in order to understand and implement Computer Mediated Health Care (CMHC).  The records in this paper are MSG’s method for an HIE.  We do this in part to reduce Stigma.  Most consumers we deal with prefer the Secrecy Of Confidentiality (SOC).
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Table – Coverage Determination - Clozapine Solutions (2017)
Treatment Preferences Revisited
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Alternatives
Prescription(s)
Amounts
Harmony
Note
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Stay the same
(2017 – Solution)
50mg 4 x at night
120 oral tablets per month
Quantity Limit (QL)
Needs demonstration
Takes an exception
(2017)
Best second choice
50mg 2 x at night
100mg 1 time at night
100 50mg oral tablets per month
30 100mg oral tablets per month
Needs potential negotiation and change of Prescription
Poor choice
100mg 2 x at night
60 100mg oral tablets per month
Probably most preferable to Harmony
Needs Change of Prescription
Poorest choice
(2018 – Fix)
Any solution that troubles us with no Clozapine (2018)
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Table – Coverage Determination - Clozapine Solutions (2017) – Treatment Preferences - Carried from 2017: Last Update: 20180302-F:
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With Housing

Along with Housing Clozapine Management are the most important and complex portions of our evolving (living) Treatment Plan.
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Syncope Side Effect – Minded Medication (MSG)
Syncope is listed as a side effect for Clozapine (CLOZARIL).  Syncope might be described as a temporary loss of consciousness caused by a fall in blood pressure.  Clozapine associated Syncope increases our risk for a fall.  We determined that “Dividing” our Clozapine doses reduces our risk of falling.  This is the reason we prefer the 50mg tablets titrated up to 200mg each night.  In addition our titration method tests our Mindful Medication Model (MSG, Triple M, 2018).  One day we will get around to publishing our findings about Triple M.  Triple M promotes optimism and self-efficacy.  As Dr. David Dobos (Kaiser) stated: “Sometimes the patient knows best”.
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Table - Report Matrix - Summary Steps (MedImpact)
Satisfaction Checklist – MedImpact Process Audit
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Step
2017
2018
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01
Prior Authorization
In Effect
In Effect
02
Need
Proven
Denied
03
Advance Notice by Mail
Yes
No
04
Reaction Time
2 Weeks
1 Day
05
Temp Fix
Yes
5 Day Emergency
06
Risk of No Clozapine
Moderate
High
On 5th Day
07
Emergency Room Diversion Value
Moderate
Low
08
Negotiation with Pharmacy
Frustrating
Frustrating
09
Phone Call Prior Authorization
à
“Denied”
20180225
SUN
10
MedImpact Authorization
“Approved”
By Mail
ß
11
Receive Appropriate Medication
Yes
Pending March
12
Discuss with Prescribing Doctor
No
Planned
13
Gain Confidence with Process
Hindsight
Unmerited
Unlikely
14
Satisfaction with MedImpact
Partial
No
15
MedImpact Promise
(“Better Care”)
False
False
16
MedImpact – Single Point Contact
None
None
Indicator for Costs and Benefits
Satisfaction with MedImpact
10/15=66.7%
3/15=20%
Star Equivalents =
3.3
1.0
Table – Results of MedImpact Process Consumer Audit – Satisfaction with Process & Provider – Qualitative to Quantitative Transformation: Last Reviewed: 20130302-F:
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Consumer Satisfaction – Satisfaction Checklist
MedImpact is a Pharmacy Benefit Manager (PBM).  One source indicates they are the largest PBM in the United States.  We here at MSG never rated a PBM.  When MedImpact sent us our (2018) Denial Document Package we were hoping to find a Satisfaction Survey.  Like doesn’t all agencies concerned about their client image issue Satisfaction Surveys.  Actually, we find no and not are the case - yet.  As you can see MedImpact lost a lot of ground since they first came on our radar in 2017.  There was a chance that we would have awarded the 1.0 Stars Score to Brand New Day (BND).
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Presenting Problem – Real Time - Loss
Let us state up front: This could be worse!  In 2017 we faced our first ever Clozapine Determination.  The result we felt was a Solution.  Now we know our 2017 effort was a Fix.  The time to Fix we have on record as: Time to Solve: 20170106 to 20170204 (About one month).  Later on we will share some of our Medical Records that chronicle the 2017 fix.  We ask: How is it this effort?  We are putting time into our 2018 MedImpact mediated Clozapine Determination because the slant is towards no Clozapine as needed.  Let us state now a gap resulting for no Clozapine has been a costly error both for us and our concerns.  If we had a probono attorney this report with them we would share.  As with the friends we dedicate our report here to: Errors can go too far leading to permanent injury and/or DEATH!  We are tired of people such as MedImpact who don’t care about us hacking our support systems.

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Introduction
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Clozapine Support – Rigid Structure
We here at MSG support a rather rigid 28-Day Clozapine Cycle for our Consumer Keith E Torkelson, MS.  After working hard to sustain our Clozapine flow last year (2017) we let our guard down.  MedImpact a Medical Billing Auditing and Cost Containment Company for 2018 denied coverage to our Clozapine.  For Keith Clozapine is his most important and essential medication.  Even in the best of times Clozapine Management require fairly complex Coordination about four Cycles.  These are the four cycle parts key to delivery of our Clozapine: Prescribing Behavioral Health Doctor (BHD); lab scheduling, attendance, and results distribution; the pharmacy; and Mr. Torkelson’s schedule of intensive Health Related Engagements (HREs).  Our persistence about a 28-Day Cycle is for effective and efficient Clozapine Management.  From 2012-2017 our BHD fit his part in with routine quarterly Medication Management Appointments (MMAs).  For the most part our routine was proven effective.
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FYI - Coverage Determination
“NCDs (National Coverage Determinations) and LCDs (Local Coverage Determinations) are decisions by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary on certain services offered by participating providers.”  There may be a chance that Medicare hired MedImpact.
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HIT-Health Information Exchange
This paper includes our real Medical Records.  It is an example of meeting Meaningful Use (MU) requirements about our Personal Health Record (PHR).  The providers still cannot share Medical Records freely.  In sharing we hope to reduce the Stigma associated with Behavioral Health.
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Program Evaluation Program (PEP) Outcome Indicators
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Outcome Indicator
MedImpact
2018
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Appropriateness of care (Service)
Probably Not
Paid and Unpaid Employment (Volunteer)
Took up some of our volunteering time
Consumer Wellbeing
Absolutely Not
Resilience Orientation
Probably So
Recovery Orientation
Probably Not
Wellness Orientation
Probably Not
Consumer/family perception of access to services
No – would have overwhelmed our family
Housing Situation
Slight negative impact
Continuity of Care
Probably No
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Table – Indicators of Impropriety (Improper Behavior): Last Reviewed: 20180307-W:
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Table - Sharing Schedule – Advocacy & Alternatives
Processes by Year
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Means
2017
2018
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Appeal
X
BND states we did
We did not
Grievance
Complaint
X
Publication
Held back due to
“Fix”
X
Retain
X
Satisfied with Fix
Direct to CMS
Option
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Table – Prescription Denial – Sharing: Last Reviewed: 20180309-F:
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Audience
These papers we right for Health & Human Service offer us little Protections.  We do it with the hope that others in need might benefit by applying some of our fixes and solutions.  This paper’s audience was initially Brand New Day.  Yet, after some investigation we determined that MedImpact, CMS, and DHCS would benefit the most.  We here at MSG earn a Health Information Transfer Credit (HITC) after we publish this paper.  We also deserve a Continuing Education Unit (CEU) for this body of work.

Table - Elements for CEU
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Element
Note
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Confidentiality
Prefer Transparency
Crisis Intervention Management
Substantial Applied Exercise
Health Information Transfer
Public Share
Meaningful Use
Technology use for betterment of health and circumstances
Para-Professional Health Worker
Treatment Planning
Steinberg Programming Language
Sprinkled here and there
Stigma Elimination
Gain comfort talking about it
Time Spent
Too Much
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Table – If Continuing Education: Last Reviewed: 20180309-F:
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Notes for CMS – Risk V Gain
Greetings CMS – Our Behavioral Health Doctor (BHD), Rimal B Bera MD, recently was named in a document from our insurer (Brand New Day) indicating that he would not provide the support we need to maintain our health and thereby keep the costs of our treatment down.  We are and have been for more than ten years dependent on daily Clozapine medication.  Chronologically through the years doctors Singh, Inglis, Vu, and Lee have worked out for us the daily dose in divided doses that work best for us.  When we were linked to our new BHD (Rimal B Bera) we were prepared to talk about treatment preferences with him.  In our ten (10) minute appointment he solicited very little if any case and treatment planning information from us.  We have had a gap in our Clozapine that resulted in hospitalization (2012).  Before we were hospitalized our chance of accidental death increased substantially.  In a manner of speaking unfortunate affairs about Clozapine can be “Life Threatening”.  Since 2012 Brand New Day has helped us more than they have harmed.  This incident could have lost all of their investment in us.
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Matrix - Results - How is it a Crisis - What Crisis?
Crisis Intervention Management (CIM)
CIM – Clozapine Crisis 2018 (February) – Thirteen Steps - Kanel Build
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#
Step/Stage
 Note
IVS-IEV
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01
Precipitation
False Trust for February Clozapine Renewal
0.5
02
Subjective Distress
Frustration and Fear
0.5
03
Coping Challenge
Ask for Emergency Supply
1.0
04
Coping Exhausted
Pharmacist cannot fill Clozapine due to lab (CBC) issues
Only one day of Clozapine left
0.5
05
Coping Challenge
Contact “Nick”  our Single Point Contact at Pharmacy
1.0
06
Brand New Day Help
History of being ineffective
0.5
07
Ask for Help (BND)
0.5
08
CCCHC Help
Psych Nurse - Bethany next – not needed
1.0
09
Intervention
“Nick”
1.0
10
Follow-up
Expected problematic based on history
20180225-SUN
MedImpact Calls with automated “Denial”
0.5
11
Follow-up
With Prescribing Doctor
0.5
12
Documentation
Letter from MedImpact
Dated
Date Received
0.5
13
Publish Report
Advocacy and Sharing
1.0
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Impact of Crisis Score =
9.0/12
75.0%
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Matrix – How is it a Crisis? - Crisis Intervention Management (CIM: 20180215-TH: Accessioned) – Last Reviewed: 20180302-F:
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Matrix - Results – Quick Score Method
Assessment for MedImpact Determination Process Challenges

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##
Feature
2017 Incident
2018 Incident
-
01
BND MedNet Grade
B
B+
02
Number of People Involved
Approximately
10
Approximately 7
03
Rate Your Pharmacy Score
Very Good
Very Good
04
ReactMan Value
Intense
Intense
05
Satisfaction with MedImpact
[CALC 16 Items]
Low
(66.7%)
Absent
(20.0%)
-
06
Satisfaction with Process
Moderate
Not
07
Satisfaction with Solution
Hindsight - Not
Moderate
08
Time to Fix
2 Months
2 Months
09
Time to Solve
Perceived Solved
Re-emerged
-
Value Added =
3.8/9
42%
3.4/9
38%
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Matrix – Results – Quick Assessment – Challenges - Service & Support Features – Sample with

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Calculations
We held back the scoring used for the calculations.  Our method of scoring we will address in a future report.

Defining a ReactMan
For us here at MSG a Reaction (ReactMan) is anything that cannot be deferred for three (3) days or 72-Hours.  We found out the day for renewal that our Clozapine could not be filled or delivered per our time tested routine.  Basically the next day we faced not having our Clozapine as prescribed.  And so we have to manage a reaction. Once a reaction begins it is very uncomfortable (panicky) and hard to stop.  We hope the reaction stops soon after we publish this paper.


Table - Key Event Logger (KEL) – Clozapine Determination 2017
-
20170106-Letter
20170109-MedImpact Letter
20170130-MedImpact Approval
20170204-Clozapine Back to Normal
-
Interpretation
Remember we tried to cope with the fact that our Clozapine supply may be interrupted to the best of our ability.  When we had to involve others and ask for help we needed an intervention.  Below are values of qualities about this Clozapine associated intervention.
-
Table – Qualities About This Intervention (2018)
-
Intervention Quality
Our Part
Pharmacy
Rimal B Bera
-
Intervention Value Score (IVS)
Good
Good
Fail
Intervention Experience Value (IEV)
Excellent
Good
Good
Danger and Opportunity
Opportunity
Danger
Danger
Who Mediated the Crisis – Precipitating Event (s)
No
No
Yes(***)
Applying CIM
Good
Good
Poor
-
20180103-W: Key Appointment – Advance Planning (***)
-
Matrix - Comparative Clozapine Transaction Summary
-
TimeStamp
Initialized
#
Transactions
Crisis
Level
Risk “911” ER to Get Medication
-
20170109-M
15
Moderate
Moderate
20180215-TH
8
High
1 Day Away - Risk High
“We are freaking out we need Clozapine”
-
Matrix – Comparative Clozapine Related Transactions for Consumer Keith E Torkelson, MS
-
Clozapine Dependence
Ever since 2006 we have been highly dependent on Clozapine a generic for Clozaril [SPELLED].  Clozapine is not to be confused with Klonopin [SPELLED].  At times the pharmacy may think we are addicted to Clozapine.  We are at our worst when someone or something is interfering with our daily flow for this our Drug Of Choice (DOC).  For some reason we cannot sleep without Clozapine.  If we do not sleep our risk for harm gets progressively worse until we have to get admitted to the Behavioral Health Ward (BHW) to be protected until we get Clozapine induced sleep.  A gap in what we call the Monthly Clozapine Cycle (MCC) or 28-day Clozapine Maintenance Cycle (28-CMC) can incur substantial costs even death.  Clozapine has a side-effect - drowsiness.  For us this means Sleep!
-
Cost of Surrender (February 19, 2018)
Our Program indicates that at some times it is wise to surrender.  If we would have surrendered when the pharmacist told us he could not help us we would have suffered a gap in our Clozapine Blood Level (CBL).
-
Closing This Issue – Action Items
Simply get back on track with our March 15, 2018 Clozapine prescription, publish this report, and let some dust settle.
-
Panic Record
We panicked when the pharmacist would not fill our prescription and offers no advise on what to do next.  He did say get your CBC done.  He rudely ended the call.  Later that day “Nick” said our CBC is up to date and has nothing to do with not getting our medication – Clozapine.
-
Table - Subjective Distress as Measured By – About Determination 2018
-
Indicator
Our Part
Pharmacy
BHD
Rimal B Bera
-
Satisfaction
Good
Pending
Waning
1 error
1 shortfall
Quality Of Life
Sustained
Sustained
Some negative impact
TeckBabble
Too much
Poor
No real technical support
See letter
-
Table - Subjective Distress as Measured By – About Determination 2018: 
Last Reviewed: 20180309-F:
-
History - Clozapine Determination 2017 – Recalling History in Scope
[FIGURES - INSERT CLOZAPINE DETERMINATION 2017]
-
January 6, 2017 Clozapine Determination
Lead Time Letter
-
Brand New Day Formulary Sample with Clozapine Quantity Limit
-
-
MedImpact Clozapine Approval
-
-
Things Back to Normal
February 3, 2017

-
Table - Figures – Records – 2017 Determination
-
Record
-
Formulary Change
Coverage Determination - Letter
Quantity Limit Issue - See Letter
Formulary (2017)
Outcome
Impact Letter
Pharmacy Receipt – Medication Resumed
-

Table – Documentation Associated with Clozapine Determination 2017: Last Reviewed: 20180309-F:
-

Table - TimeSpent - Scanning Efforts (Applied Materials and Method)
TimeStamp
Document
20180228-W
Prescription Summaries
20180217-SAT
Determination 2017
20180302-F
MedImpact Denial Letter
20180308-TH
Letter Doctor Bera Agrees not to Support Us
Table – Scanning Efforts Associated with MedImpact Clozapine Crisis: Last Reviewed: 20180303-SAT:
-
2017 Turnaround – 28 Days
On Monday, January 9, 2017 we received at letter by mail from Brand New Day - (Harmony Dual Access) regarding a Quantity Limit for our 50mg tried and proven medication Clozapine.  On Monday, January 30, 2017 we received a letter by mail from MedImpact.  The MedImpact letter dated 01/23/2017 stated “Request…approved”.  The time for us to “Fix” the Clozapine issue spanned 20170106 to 20170204 or about one month.
-
TransActor Transaction Summary (Counting Transactions) 2017 and New Incidence 2018
-
Key Date
Approximate
Transaction #
TimeSpent
About…
-
20170109-M LiveX
15
20170106-20170204
30 days
20180215-TH LiveX
12
20180215-20180316
30 days
-
Matrix – MedImpact Associated Transaction Summary (TransActor): Last Updated: 20180307-W:
-
Status Life-threatening
Once again a chain of causality can link issues with our Clozapine to life-threatening situations.  The last time we were at danger for accidental death was 2012.  One of the reasons we were safe from 2013-2017 was because our Clozapine pipeline was kept intact.  Problems with Clozapine put us at risk by breaking our Continuity Of Care (COC).  We would like to find the Contract Administrator with Brand New Day (BND) who is in charge of the MedImpact contract.  There is really not chance BND will replace MedImpact because in other cases the benefit to BND most likely far outweigh the cost to retain MedImpact.
-
HEALTHMAN Level – Complaint
As a result of this work we are investigating the framework for our HEALTHMAN standalone blog.  In one of the first papers we will publish our DocMan (Doctor Manager) chapter (post).
-
STR Method
We used our Structure Temporal Reconciliation (STR) Method to cope with this issue an issue that has been causing us stress for more than one (1) month now.
-
Rework – Do Over
Last year, 2017, we were given a bit of lead-time because the Determination Conflict came by mail.  When the 2017 Determination challenged our Clozapine interests we did not publish a report because the issue was fixed.  Our Clozapine supply continued without interruption.  We were for the most part Satisfied.  We put the stress and reactivity behind us.  We had planned to Publish a report on Medication Determinations in due time.  And now how fast a year passes.  This year, 2018, we did not get a letter in advance with regards to the same issue as last year.  We found out from our pharmacy, Gilbert Drugs, that they could not refill our Clozapine Prescription as written.
-
How is it Life Threatening?
Historically, interference with our Clozapine supply can snowball into Major Crises including Hospitalization.  We worked out an elegant mechanism.  Roughly, no Clozapine > No Sleep > Increases Anxiety > Panic for 72 hours or less > “911” > Release with no Clozapine > More Panic > Increase Chance for Accidental Death.
-
Single Point Contact
The person in charge of Medication Management is the Behavioral Health Doctor (Psychiatrist). 
Last year the key players were “Nick” at the Pharmacy and “Bethany” at our Psychiatrist office.
-
Who is Accountable?
What is there to be accountable for?  We here at MSG have a working definition for Accountability.  Money!  In the instance of MedImpact this year (2018) in order to save a little money they risked incurring substantial costs about Brand New Day (BND) and us.  As of yet: Our Behavioral Health Doctor (BHD), Brand New Day (BND), Gilbert Pharmacy, and MedImpact are not accountable.
-
Table - 2018 Coping Time Line > Step Summary
Event Timeline
-
TimeStamp
Step (Action)
Persons & Notes
-
20180215-TH
Call Gilbert Pharmacy for Routine Refill on Clozapine
Brand New Day
(Harmony Dual Access)
Clozapine QL Issue
20180215-TH
Gal says OK
She calls back later
We cannot fill prescription as written – ReactMan
Will take 3 days to sort it out
20180215-TH
I ask for emergency supply
They deliver 5 days worth  (Patched)
Lab work only 22 days old
- From 20180124-W
20180217-SAT
Revived Report
Determination (2017)
20180217-SAT
Call Gilbert @ 10am
“Has our Clozapine been worked out”
Response “No – nothing from doctor”
I will call back Monday
20180219-M
Call Gilbert
Pharmacist say he will not fill our prescription for Clozapine
20180219-M
Call Gilbert for SPC “Nick”
We agree on 100mg tablets
Say he will deliver tonight
20180225-SUN
Incoming Call @317pm
MedImpact “Denial”
-
20180301-TH
Received Letter
MedImpact “Denial”
20180308-TH
Received Unexpected Letter From Brand New Day
Brand New Day and Dr. Bera “Close” File on issue
20180312-M
Give Gilbert 3 days lead time
Call on Monday for prescription on Thursday (20180315-TH)
20180314-W
Emergency Drop-in
Need to see Doctor Bera Clozapine is not on track by 20180313-TU
20180315-TH
Wait for delivery
Hope for the best
20180316-F
Publish findings
Actually earlier to begin closure
-
Table - 2018 Time Line > Step Summary: Last Update: 20180307-W:
-
ItSaFriday! - Worst Day for Problems
Due to the fact that a majority of Health & Human Services providers are not open weekends we posit that the worst day of the week for a health related problem is Friday.
-
Table - Qualities to End This Crisis (CIM)
-
Quality
Note
-
28-Day Clozapine Cycle Restored
Contact Pharmacy giving lead time of 3-days or greater
Most important adjustment made for 2018
Medication Delivered Correctly
Share Subjective Distress Online
Normalize In Scope frustration, disappointment, and fear
Make a Big Deal out of a Big Deal
Discuss this process with our Behavioral Health Doctor (BHD)
Publish This Report for Closure
Once our March Clozapine arrives we will charter this report
Key date March 15, 2018
Separate out findings and apply PRN
Add MedImpact to our annual Christmas Report Card (CRC)
Hope for MedImpact to send us a Satisfaction Survey
-
Table - Qualities to End This Crisis: Last Reviewed: 20180307-W:
-
Fix V Solution
Last year (2017) we thought that the Quantity Limit issue with Clozapine was Solved.  We worked on it the better part of a month.  So this year we will classify the Quantity Limit issue 2017 as a Fix.  The difference between and Solution and a Fix is the former never comes up again.
-
Date: 20180119-M: What is the issue?
Urgent Clozapine Issue
Need my Clozapine refilled as soon as possible.  Pharmacy emergency supply will run out today.  I have an Emergency Supply provided by Dr. BS Lee.  Pharmacy says there is a BND Quantity Limit issue.  I called Gilbert Drugs per routine January 15, 2018 (Thursday).  They said there is a Quantity Limit on my usual 50mg four a day.  They said it would take time to sort it out.  Called January 19, 2018 (Monday at 930am).  Pharmacist says he will not help me until I have my lab work (CBC) run and sent over. 
-
CBC Complications
Our routine Clozapine related CBC was last run on January 24 (Wednesday).  When we called the pharmacy originally on the 15th our CBC was only 22 days old.  Today, January 19th our lab work is 26 days old.  The pharmacist will not accept it.  We were led to believe monthly lab work was good for 28 days or even 1 month.  Last year (2017) when we faced a similar challenge BND informed us by letter that gave us about three (3) weeks to sort things our without risking a gap in our Clozapine or messing up our Clozapine Maintenance Cycle.
-
Summary (Needs)
-
Help getting our Clozapine Refill ASAP
Help to address BND Quantity Limit on Clozapine
Help for Gilbert to sort our Lab work Issues
Help to re-address BND Quantity Limit on Clozapine
Will rely on Emergency Supply Accrued while under the care of Dr. Lee
This trends towards harmful
-
Crisis & Continuity
This incident is now approaching a crisis because we have nearly exhausted our means to cope.  We now have to ask for outside support.  Continuity about our Clozapine is now our most urgent and prominent concern.  We may have to reduce our daily dose to maintain Clozapine in our blood and systems.
-
Thank you for your consideration
Keith E Torkelson, MS
-
Treatment Preferences – Do Over
Even though we thought we had promoted our Treatment Preference enough for 2017 we now find we must commit to a “Do Over”.  Healthcare Reform Measures (HRMs) indicate Consumer-driven Treatment Preferences (CTPs) are desirable.  Actually promoting them has proven to be a hard sell.  In 2016 our Behavioral Health Doctor (BHD) indicated that our preferences would not be honored in an inpatient setting.  Basically, he said he would not honor them in an inpatient setting.  This BHD is about 77 years old – he will be retiring soon.  He retires without publishing anything that proves his “Practice” was successful.  That is sad a whole life and nothing as a doctor to be proud about and survive him.
-
How is it 3-month Lead Time?
On important issues such “Denying” crucial medication it would be best to give the victim three (3) months lead time.  In 2017 MedImpact gave us a month.  In 2018 MedImpact gave us a day.

Benefits – Notions to Facts – Eligibility Duration the Lab Work (CBC)
Instead of going into details why Gilbert has inferior quality service as compared to CVC let us say we have to learn more Clozapine nuances.  One is how long does the monthly lab work (CBC) associated with Clozapine remain valid for the Clozapine Registry.  The point is: If the pharmacy does not accept the lab work while covering their tails a real mess ensues.  What was fortunate about this year’s (2018) MedImpact Determination is that we caught a cycle slip.  Our lab work which is best under two weeks old was approaching 28 days old.  We were able to argue successfully for an Interim CBC.  Our lab till prescription interval is now less than two weeks.  Thank you MedImpact at least for this outcome. 

Table – Documentation – MedImpact Clozapine Determination 2017

Table – Documentation – MedImpact Clozapine Determination 2017
-
Clozapine Determination 2017 - Documents & Documentation
The materials we used for arguing our need for Clozapine as prescribed from 2012-2016 are in the list above.
-
***Brand New Day HMO and SNPs 2017 Part D Formulary - ID: 17054.000 Version: 7 AKA “Formulary”

**Bethany is our Psych Nurse

*BSL was our Behavioral Health Doctor (BHD) from 2012-2017
-
Seeing is Believing
Remember all we are trying to do is secure the medication that has proven successful for us since 2007.  Our last Behavioral Health Doctor (BHD) Bum Soo Lee had us stable on 50mg Clozapine in divided dose for more than five (5) years.
-
[COPIED TO RATE YOUR PHARMACY]
-
Role of the Pharmacy - Rate Your Pharmacy (RYP)
We publish MSG’s detailed Rate Your Pharmacy findings at the end of each year with our Christmas Report Card (CRC).  Briefly, our pharmacy Gilbert Drugs (Garden Grove) performed better with our Clozapine Determination in 2017 than they have in 2018.  If it were not for our Single Point Contact (SPC) “Nick” we would begin the process of firing them.  Gilbert really doesn’t value our business.  When it comes to Clozapine changing pharmacy is not a simple matter.  Gilbert Pharmacy is far inferior to CVS when it comes to managing the Clozapine Mandated Lab Work (CMLW).  CVS was our pharmacy from 2007-2012.  They never asked as Gilbert often does: Did you get your Lab done?  They knew that I would not be talking to them unless the lab work was done.
-
FYI – Legacy Post
Keith Edward Torkelson, MS – LiveX – Christmas Report Card 2016 – Grade Your Health Network – Quality Assurance in Health Care
No Rate Your Pharmacy (RYP) - Saturday, December 10, 2016 – Quality Control
-
ComMan – How is it a Complaint?
We here at MSG classify challenges as Reactive, Complaint, Merit, etc.  Our Complaint classification is reserved for injury that we may take to court.  Complaints generally have substantial direct and indirect costs associated with them.  In this incidence of this Clozapine Determination it would be the cost of hospitalization and/or the cost of accidental injury. We use records such as Transaction Logs to help of make sense of a hurdle or challenge.  Over time using our Concern Manager we have developed a Medication Management Network (MMN) that includes a few Single Point Contacts (SPC).  Since 2012, the year we hired BND, we have logged people-resources about the Program, BND, CCCHC, and the BND/CCCHC Complex.  We noted that Staff Friendliness and Courteousness goes a long way for solving problems.  Our time spent here at MSG has yet to be fully valued.
-
Medications – Comparing Costs
Brand New Day most likely paid more for the Determination that they will save for the whole of 2018.
-
[SCAN JOB – JANARY 2018 – 2017 EOY STATEMENT]
[REFERENCE JANUARY STATEMENT AGAIN]
-

-
20170113-F: Have them contact doctor: “Ana L” refused service and support role
Transcript – 1230am - Brand New Day Customer Service
We followed the instructions in problem definition letter and called Customer Service for support.  We reached Ana L.  Aside of her fear for giving a full last name rather than “L” being an accountability issue, Ana L. said that she could not help me.  Ana said I needed to contact the prescribing doctor.  I indicated that she might be saying I can’t help you - you fix it.  I indicated that neither my doctor nor I had caused the problem.  She said contact the prescribing doctor.  To paraphrase she said: She could not provide the need services or support and that I fix the problem myself.  Instead of me getting a letter defining a problem, it would have been nice to get a letter of how and when to contact the doctor for a one time guaranteed transaction.
-
Definitions
-
What is XENONET V MedNet?
For a while we here at MSG used MedNet and XENONET interchangably.  The brief difference is that MedNet we have more control over then XENONET  Receiving a Determination is an example of something we here at MSG have no control over.  We have power to contact or transact with Key Individuals yet not much over their Level Of Helpfulness (LOH).  At last check CMS awarded Brand New Day 3.5 Stars.  It is very likely that MedImpact and the MedImpact Process are promoting BND’s Performance As Measured By (AMB) CMS Stars.
-
How is it MedNet?
The most important feature of MSG’s MedNet (Prescription) Safety Net system is that we can document, collect records, mill things over, and report our findings over the Internet.  We also can control our pacing a bit unless the issue, such as this, requires an elevated level of Reactivity to fix or solve.
-
How is it XENONET?
What we have less or no control over?  On this we here at MSG have little or no control over external policies, procedures, and protocol.  In addition, we cannot completely control the reactions of those with whom we seek help.  XENONET is MSG’s product line associated with the aspects of Medication Management we have little to no control. 
-
Matrix - Safety Net Comparisons – Context Medication Determinations – Balanced Scorecard
-
Safety Net
Our Part
S&S
-
MedNet2017 Grade (MN2017G)
A
B
MedNet2018 Grade (MN2018G)
A
F
XENONET2017
A
B
XENONET2018
A
C
-
BND/CCCHC Complex 2017
A
A
BND/CCCHC Complex 2018
B
C
Pharmacy 2017
A
B
Pharmacy 2018
A
B
-
MedImpact 2017
B
B
MedImpact 2018
B
F
-
Behavioral Health Doctor
Bum Soo Lee (2012-2017)
A
B+
Behavioral Health Doctor
Rimal B Bera (2018)
B
D
Table – Balanced Score Card – 2017 & 2018 Clozapine Determinations: Last Reviewed: 20180302-F: S&S = Services and Supports
-


Consumer Satisfaction Revisited
For us here at MSG sometimes it is tricky identifying the Belligerent/Belligerents.  In 2017 the Belligerents were: The Axis Powers: Brand New Day, Central City Community Health Center, Gilbert Pharmacy, and MedImpact pitted against us The Allies.  We won!  In 2018 since MedImpact had the Intel collected in 2017 they are our primary “Enemy” for 2018.  For 2018 as you can see by the “F” Grade they failed in negotiations.  For us as a Consumer we are not “Satisfied” with MedImpact’s work for this year (2018).  The last form set that MedImpact sent us by mail included forms for “Appealing”.  Rather pursue their route we choose this year to publish our findings over the Internet.
-
January 15, 2017 [Patient Name – Keith Torkelson]
For our 2017 Clozapine Determination (CD) we documented our concerns in writing.  We had some odd fifteen days to “freak out” knowing we may not get our next Clozapine prescription on time.  We wrote a letter to our Behavioral Health Doctor (BHD), Dr. Bum Soo Lee, and delivered it by hand to Cynthia (Office Manager) for her to pass it on to our Psych Nurse Bethany.  All of the people in the chain are associated with the Brand New Day “PowerHouse” provider (contractor) Central City Community Health Center (CCCHC).  In the end our Need was proven for Clozapine as is and we were able to continue without a gap with this our tried and tested Clozapine Regimen first established with our BHD in August 2012.
-
Coverage Determination (CD-Clozapine, 2017)
On January 9, 2017 MSG received the following letter from our “SuperProvider” Brand New Day (BND-Harmony Dual Access) Member Services.  The letter addresses a Quantity Limitation (QL) for our Clozapine 50 mg oral tablet.  During the course of 2016 our Behavioral Health Doctor (BHD), Bum Soo Lee prescribed us 50mg four times at bedtime.  The total number of 50 mg Clozapine tablets was 120 per month.  The reason we take 50mg at a time four times per night is that smaller doses decrease our chances of falling.  On Friday January 13, 2017 we called for Technical Assistance (TA) @ the BND phone number 866-255-4795.  The Technical Rep “Ana” said to solve the problem ourselves by contacting the prescribing doctor.  Just a side note – For us Fridays are the worst day to development problems.  More often than not BHDs cannot be reached over the weekend.
-
20170109-M – Last Year’s Clozapine Crisis
HEALTHMAN - ReactMan – Freak Out No Clozapine
As you saw earlier this Coverage Determination stems from a Quantity Limit (QL) presented in the BND Formulary.  The quantity limit that affects (effects) us is Count 90 – 50mg tablets per month.  You should already have picked up earlier in this report that for more than 3 years we have been stable on 120 – 50 mg tablets per month.
-
Could Be Worse
In our past we had several serious issues maintaining our Clozapine supply.  In a manner our life depends on reliability and continuity with our Clozapine.  Two failures about supply are: HealthNet our insurance HealthNet in 2011 stopped covering our (CBC) lab work.  Monthly lab work is required prior to a pharmacy filling any Clozapine prescription.  Another example was a doctor (Daniels), without taking our history, cancelled our Clozapine.  The risk for accidental death increased and we suffered a Hospitalization bill to the tune of $15,000.00.
-
Treatment Preferences Revisited
Once again we are going to address the Treatment Preference Hurdle (TPH).  After a dozen and more medication experiments since 1989 we found one that is more helpful than harmful – Clozapine.  We have tried to get our preference in the record in the Health & Human Services cloud.  Once again the reason we prefer 50mg tablet in four Divided Doses is that it reduces the risk of falling.  On one fall while we were in Huntington Beach Hospital we sustained a bleeding head injury.  Brand New Day should include our Treatment Preferences in their Cerecons Aerial Patient Portal.  In this instance our TPs didn’t change rather we had to surrender to keep our Clozapine flowing.
-
Link to Treatment Preferences [AN UNSOLICITED LEGACY DOCUMENT]
-
Brand New Day HMO: Thursday, December 14, 2017   
Keith Edward Torkelson – Treatment Preferences – Behavioral Health Medication - Positions Mental Health Treatment Preferences for Keith Edward Torkelson M.S.
MSG-Health Man
HealthMan – ReactMan Utility
How is it a reaction?
If any health concern needs to be addressed within three (3) days we here at MSG call it a reaction.  We try our best to avoid reactivity.  Too much reactivity harms us.  Two areas about our health elicit our reaction: 1) Issues with Clozapine and 2) Issues with sleep.  To a lesser extend we react to housing concerns as well.
-
Fixes V Solutions (2017)
Fixes temporarily resolve issues whereas solutions solve the issue for more that six (6) months.  In the case of this Clozapine Determination the solution will occur when our next prescription arrives on time and at the approved dosing.  As far as this year’s Clozapine Cycle it is very unlikely we will achieve a solution.  We have sixteen (16) Clozapine associated appointments to get right for the upcoming year (2017).  For 2016 we kept all of our Clozapine associated appointments.  That is MedNet in action!
-
Fixes V Solutions (2018)
Fixes temporarily resolve issues whereas solutions solve the issue for more that six (6) months.  In the case of this Clozapine Determination the solution will occur when our next prescription arrives on time and at the approved dosing.  As far as the year Clozapine cycle it is very unlikely we will achieve a solution.  We have sixteen (16) Clozapine associated appointments to get right for the upcoming year – 2018).  For 2017 we kept all of our Clozapine associated appointments.
-
Risk V Benefit - Conclusion
Even though it appears we will be able to work through this issue with managing our Clozapine the risks presented by MedImpact outweigh any benefits for: MedImpact, Brand New Day or ourselves.  We negotiated with our pharmacy, Gilbert Drugs, twice to keep our medication flowing.  We cannot close this issue until we get our next prescription (March) filled without a hitch.  Our new Behavioral Health Doctor (BHD), Rimal B Bera, was not helpful at all.  We saw him in January and he didn’t even give us a heads up that a Clozapine Determination was pending.  MedImpact did not give us an advance notice letter this year (2018) as they had in 2017.  At one point we panicked which is not the best state of mind for us.  If CMS reads this and wishes to respond our email is “ktork46@yahoo.com”.  We do not expect response to this report from: MedImpact, Brand New Day or CMS because this “Unsolicited”.
-
Table - Charter Information
-
Specification
Detail
Comment
-
Name of Post
Clozapine Practical LiveX by Keith E Torkelson, M.Sci.
(Number not assigned)
Coverage Determination
(Clozapine)
The Assignment
IBDP
Extended Essay
Class
Risk Management
Number
Cypress College – Continuation Studies
Crisis Intervention Management
Teacher/Mentor
Arnold P Deutsch, MD
Psychiatry (Retired)
Term
Winter 2018
Credit
Submitted for Partial Credit
Rate Your Series
External Quality Review
Agency/Agencies
MedImpact
CMS
Method
Problem Solving & Coping
Medication Errors
HEALTHMAN
HealthMan Utility
ReactMan2018
Date Chartered
March 9, 2018 (Friday)
Target Close Date
March 29, 2018
Name of Blog(s)
Clozapine
Brand New Day
Number of Associated Posts
Progressive and Formative
Number of Images
< 10 Photos
About 20 Figures
Including Medical Records
Links
PENDING
-
Matrix – Charter Information for Determination- MedImpact
-
Hashtags
-
#APD #JET #GGT #Buster #Hansen #CMS

-

-

-
Another Peer's Medication - "Best Ever"
-

-
The Hospital Alternative (Day Rates)
-
Google our most important Partner
-
-
Mark Guess How & Why He Died
-
-
Doctor Bera our Hope for the Future
-

-
Remember the mass of medications above
They were Dug's
Note he was serviced by BND contracted psychiatrists
What they do right really has an impact
Dug Died Too Young

End of Report


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