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September 5, 2009

STEPHANIE SALTER: Medical stories that have zero to do with the HC reform fight

By Stephanie Salter

TERRE HAUTE — Two items today about what we used to call “going to the doctor” or “being in the hospital,” but now refer to with a word or term whose initials are “HC.”

(Not only am I bone-weary of the HC “debate,” which really is a depressing standoff between angry citizens, I don’t want to contribute one more e-item to the existing Internet HC tsunami. Recent Google estimates for the HC-word are staggering. Spelled as one word, with or without a hyphen — 134 million citations; as two words — 161 million.)

Item No. 1: Not long ago, a letter came to the editor here from Margaret Crowder, a 76-year-old Lyford woman who had a double mastectomy for breast cancer in 2007. Back home from a visit to her native England — which ended prematurely when she suffered a stroke — Crowder called the Boutique at Clara Fairbanks breast health center to see about getting some replacement prostheses.

In the chaos of her trans-Atlantic flight after the stroke, some of the contents of her luggage were lost, including special mastectomy bras and backup prostheses. To her unhappy surprise, Crowder learned, “I’m on the bottom of a very, very long list” for prostheses that would be reimbursed, as she was accustomed, by Medicare.

“I can’t tell you what a nightmare the last few months have been,” she said, by telephone. “I had five major surgeries after the mastectomies because of complications. I needed a break, so I went to England — and had a stroke! I have hearing aids, and they were lost, too — $3,000 for new ones.”

As traumatic as a double mastectomy was, Crowder said, “Thank God for the prostheses. At least they make me feel like a woman. I may be 76, but I cut my own grass and clean my house every week. Now I find out I’ll have to wait, I don’t know how long, to get new ones and a proper bra. This is devastating.”

Kristi Roshel, in the public relations department of Union Hospital (Clara Fairbanks is part of it), explained a good deal about what happened to Crowder.

“Government regulations are changing in the coverage of our post mastectomy supplies by requiring them to only be sold as ‘Durable Medical Equipment,’’ Roshel wrote in an e-mail. “This requires an additional licensure and accreditation process that we hope to have complete this fall.

“Our certified fitter sees approximately 35 women a month for prostheses and postmastectomy supplies. The majority of these are not new customers and don’t mind waiting until their products are covered for reimbursement. The products are still available for the those who have recently had a mastectomy and are first time customers, however they will not be reimbursed at this time.”

A ’net search provided more information. The coverage changes appear to be an eventuality of the Medicare Modernization Act of 2003. Any suppliers of post-mastectomy items, such as prostheses, who have not submitted all the necessary paperwork for re-licensing and accreditation will be out of the Medicare payment loop after Oct. 1.

Obviously, that isn’t an issue for the Boutique at Clara Fairbanks, which has done the work, but a wait for recertification is an issue, as are the coverage changes. For example, prosthetics covered by Medicare can be replaced now only every 24 months instead of every 12 months.

An online guide for Medicare beneficiaries says mastectomy bras are “covered as needed.” The guide also says there is no coverage “for replacement prostheses due to wear and tear before the specified time frames,” but coverage will apply for “Loss, Irreparable damage, or Change in medical condition,” i.e. a large gain or loss of weight.

Where all this leaves Crowder, who still has one set of prostheses but no backups, is not quite clear, but Roshel noted in her e-mail:

“We are happy to work with each individual on a case-by-case basis to help with the best treatment plan for them. We pride ourselves in being the only local provider with a certified fitter for this service and appreciate the patience our customers have shared with us.”

Roshel also said that Clara Fairbanks expects its relicensing and certification process “to be complete and reimbursement fully restored this fall.”

From what I could glean from the Internet, a single silicone breast prosthesis runs about $190 retail and before tax. But a prosthesis isn’t like a pair of pantyhose you can just dash into Walgreens to buy; certified fitters and proper bras are important elements of a successful package.

But as Crowder said, “After the hearing aids, if I had to buy prostheses, hell’s bells, I’d be broke altogether.”

Stay tuned.

Item No. 2 is about what we used to call “medicine,” back when we called the HC-word “going to the doctor” or “being in the hospital.” Now medicine is called “prescription drugs” or “pharmaceuticals.”

This past week, one of the behemoths of the pharmaceutical industry, Pfizer, agreed to pay $2.3 billion to settle criminal and civil cases against it in its marketing of a now-withdrawn drug called Bextra and several other drugs.

Repeat: $2.3 billion.

The New York Times business section classified the amount as the largest HC “fraud settlement and the largest criminal fine of any kind ever.”

Ever? That’s big. Much bigger than the $430 million Pfizer paid in 2004 to settle a similar illegal marketing suit over a different drug, Neurontin, or the two other multimillion-dollar settlements the company had agreed to in the two years before that.

The best piece? As part of the 2004 settlement, Pfizer pledged, in writing, to corporate integrity, promising not to do what it had done with Neurontin ever again.

Pfizer is hardly alone in this marketing hanky-panky, which is basically the seducing of doctors to prescribe a drug that is approved for one malady for treatment of another malady for which the drug hasn’t been approved. In January, fellow behemoth Eli Lilly made a lot of federal untidiness go away over its drug Zyprexa by agreeing to pay $1.4 billion in fines.

The absolute best piece? This sentence from last week’s Pfizer story in the Times: “While the government said the fine was a record sum, the $2.3 billion fine amounts to less than three weeks of Pfizer’s sales.”



Stephanie Salter can be reached at (812) 231-4229 or stephanie.salter@tribstar.com.

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