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”.
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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[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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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.
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.”
“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
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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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
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
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).
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
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)
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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.
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
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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##
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Promise
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PBM 2017
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PBM 2018
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||||
01
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Effective Management
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0.5
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0.0
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Lower Cost
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1.0
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0.0
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Better Care
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0.0
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0.0
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||
Client Alignment
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0.5
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0.0
|
||
05
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Lower-net-cost
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1.0
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0.5
|
|
Medically Appropriated Drugs
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1.0
|
0.5
|
||
Good Value
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0.5
|
0.0
|
||
High Quality Service
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0.5
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0.0
|
||
Client Satisfaction
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0.5
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0.0
|
||
10
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Flexible Solutions
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0.5
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0.0
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Member-Centric
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0.5
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0.5
|
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Timely Information
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0.5
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0.0
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13
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Important Information
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1.0
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1.0
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Quality Outcome Score
[MEASURE OF SATISFACTION]
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8.0/1
61.5%
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2.5/13
19.2%
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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.
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
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
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Clozapine
Amt Assumed
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Note
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Your Paid - The Consumer
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$1.25
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Plan Paid - The Insurer
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$0.00
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Assume Brand New Day
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Other Payments - Extra Help
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$103.35
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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
A Second Look
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HIE-Health Information Exchange
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
Treatment Preferences Revisited
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Alternatives
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Prescription(s)
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Amounts
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Harmony
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Note
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Stay the same
(2017 – Solution)
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50mg 4 x at night
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120 oral tablets per month
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Quantity Limit (QL)
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Needs demonstration
Takes an exception
(2017)
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Best second choice
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50mg 2 x at night
100mg 1 time at night
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100 50mg oral tablets per month
30 100mg oral tablets per month
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Needs potential negotiation and
change of Prescription
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Poor choice
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100mg 2 x at night
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60 100mg oral tablets per month
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Probably most preferable to Harmony
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Needs Change of Prescription
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Poorest choice
(2018 – Fix)
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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
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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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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
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2017
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2018
|
|||
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|
|||||
01
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Prior Authorization
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In Effect
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In Effect
|
||
02
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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
|
|||
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Consumer Satisfaction – Satisfaction Checklist
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).
-
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
-
-
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.
-
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.
-
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.
“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.
-
HIT-Health Information Exchange
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.
-
Program Evaluation Program (PEP) Outcome Indicators
Program Evaluation Program (PEP) Outcome Indicators
-
|
||||
Outcome Indicator
|
MedImpact
2018
|
|||
-
|
||||
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
|
|||
-
|
Table – Indicators of
Impropriety (Improper Behavior): Last Reviewed: 20180307-W:
-
Table - Sharing Schedule – Advocacy & Alternatives
Processes by Year
-
|
||||
Means
|
2017
|
2018
|
||
-
|
||||
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
|
|||
-
|
Table – Prescription Denial – Sharing: Last Reviewed:
20180309-F:
-
-
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.
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
-
|
|||
Element
|
Note
|
||
-
|
|||
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
|
||
-
|
Table – If
Continuing Education: Last Reviewed: 20180309-F:
-
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.
-
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.
-
FYI - https://www.cms.gov
-
Matrix - Results - How is it a Crisis - What Crisis?
Crisis Intervention Management (CIM)
CIM – Clozapine Crisis 2018 (February) – Thirteen Steps - Kanel Build
CIM – Clozapine Crisis 2018 (February) – Thirteen Steps - Kanel Build
-
|
|||||
#
|
Step/Stage
|
Note
|
IVS-IEV
|
||
-
|
|||||
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
|
||
-
|
|||||
Impact of Crisis Score =
|
9.0/12
75.0%
|
||||
-
|
Matrix – How is it a Crisis? - Crisis Intervention
Management (CIM: 20180215-TH: Accessioned) – Last Reviewed: 20180302-F:
-
Matrix - Results – Quick Score Method
Assessment for MedImpact Determination Process Challenges
Assessment for MedImpact Determination Process Challenges
-
|
||||||
##
|
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%
|
||||
-
|
Matrix – Results – Quick Assessment – Challenges - Service
& Support Features – Sample with
-
Calculations
We held back the scoring used for the calculations. Our method of scoring we will address in a future report.
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.
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
-
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.
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
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!
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
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
-
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.
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.
-
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).
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
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.
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).
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
-
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
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)
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.
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.
-
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
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.
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
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”
***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.
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.
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]
[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.
-
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.
-
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.
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)
suhagra 100 mg is a physician recommended medication used to treat erectile dysfunction in men. It works by expanding blood stream to the penis. This assists men with getting or keep an erection. It has a place with a gathering of drugs known as phosphodiesterase type 5 (PDE 5) inhibitors. Suhagra 100 Tablet might be taken on a vacant stomach or with a feast.
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