Medicare's new plan to reduce hospital overcrowding

In principle, the idea behind this is actually quite good because there are so many logical gaps in the current system. Of course, new ones will pop up, they'll just be in different places.

The worst part, though, is the patients themselves—people who visit doctors, get a whole stack of prescriptions, and then just DON'T TAKE THEM. Or they don't finish the course, or they take them incorrectly. I actually overheard a guy bragging to a pharmacist the other day about how he keeps his medication sitting right in his desk drawer, yet he still makes sure to pick up one or two boxes every single month regardless!

Then you have the patients who get a tiny little twinge in their ear and suddenly demand a full-body CT scan and every diagnostic test known to man.
Or the hypochondriacs and people with severe anxiety who spend YEARS cycling through doctors, running enough tests on the healthcare system to cover ten people, when all they really need is for someone to finally refer them to a psychiatrist. But no, these same Primary Care Physicians insist on writing referrals for heart checks, blood work, thyroid panels, brain scans, this and that... even though the patient is clearly just anxious. It’s like these PCPs should be psychiatrists instead, because every single one of these patients just wants physical proof of a disease. Do we realize how much that costs us?

As for asthma, it’s just "lovely" to hear people dismiss it as some minor, insignificant condition that doesn't require a specialist.
I’ve been on the brink of death a couple of times—struggling to breathe, my oxygen saturation levels tanking... but heaven forbid I actually see my own pulmonologist!
Generally speaking, it feels like the shortage of pulmonologists isn't even a result of this new reform; it's been bad for a long time. Specifically:

I have my own pulmonologist. She sees me maybe once every two or three years just for routine maintenance. My asthma is under control, and my PCP handles my prescriptions. However, if my condition starts to take a turn for the worse—I CANNOT GET TO HER!!!!
I can get an appointment in a month. Wtf? The nurse tells me, "If it's an emergency, call 911; if you're feeling slightly worse, go to your primary care doctor." So what is the point of having a specialist pulmonologist managing my care? If I can't see her exactly when a flare-up happens, what's she there for?
Is she just there for routine checkups when I'm feeling perfectly fine? I don't even need her for that!

The only time I actually want to see a pulmonologist is when I feel my asthma worsening, but BEFORE it reaches the point where I need to call an ambulance!!!!!

It was the same thing back when I was a student and had my records at the campus health clinic; they had a habit of scheduling appointments a month out.
The only way you got seen the same day was if you had a high fever or active bleeding.

That just isn't normal. Even if you have a minor inflammation or something is aching or burning... what is the logic in waiting a month for an appointment, letting everything get worse, spread, and complicate itself, and just suffering through it for thirty days???
Especially since gynecological issues aren't things you should wait on, aside from regular screenings.
It’s like going to a PCP with a throat infection or a bladder infection and being told to come back in a month because it's "not an emergency."

That’s actually how I ended up finding a private gynecologist whom I can see the same day or the next. And that was the first time in my life someone actually asked me, "Have you had your swabs done?" What do you mean, swabs? Heaven forbid a government doctor would suggest that a sexually active person might actually need to get tested once in their life.
☕

Kyle Lee7 said:If you ask me, there’s no such thing as "psychotherapy in the full sense of the word"—nor is there any such thing as "semi-psychotherapy." You either perform it, or you don't.
Given that becoming a licensed psychotherapist requires years of specialized training and practice, and considering that a standard therapy session lasts 45 minutes while the waiting room at my local clinic is packed with 30 people (my doctor sees anywhere from 60 to 90 patients a day!), I just don't see how any kind of "partial psychotherapy" (like simple talk therapy) could possibly happen in that setting.

I’m sharing this from the perspective of someone who has been in psychotherapy for several years now.

If you look at the billing codes in a standard primary care clinic, Kyle Lee7, you'll see entries for things like "psychotherapeutic counseling" or "superficial psychotherapeutic intervention."

Since I'm no longer working in general practice, I can't give you the exact specifics right now, but these are procedures that don't require advanced training. A standard MD can perform them without being a specialist in family medicine.

So, this "semi-psychotherapy" does exist, and it gets billed—Medicare covers it under certain outpatient procedure codes.

There's no need to question my understanding of psychotherapy. This isn't an official medical seminar, nor is it intended to be a formal academic debate, so precision isn't the priority here.

Thanks.

vividsailor7 said:
Nicholas Myers, regarding the generics issue—this new model for prescribing drugs—what's your view on what Morgan Morgan5 mentioned about people not even knowing the original brand name? It's something I've noted before as well.

I agree with everything said here.
🙂

Nicholas Myers said:If you look at the billing codes in a standard primary care clinic, Kyle Lee7, you'll see entries for things like "psychotherapeutic counseling" or "superficial psychotherapeutic intervention."

Since I'm no longer working in general practice, I can't give you the exact specifics right now, but these are procedures that don't require advanced training. A standard MD can perform them without being a specialist in family medicine.

So, this "semi-psychotherapy" does exist, and it gets billed—Medicare covers it under certain outpatient procedure codes.

There's no need to question my understanding of psychotherapy. This isn't an official medical seminar, nor is it intended to be a formal academic debate, so precision isn't the priority here.

Thanks.

I agree with everything said here.
🙂

My apologies, I really didn't mean to call you out like that.

I was just expressing my skepticism regarding any kind of psychotherapy intervention being handled by general practitioners—regardless of the specific type. I actually wasn't aware that "psychotherapeutic counseling" was even a formal term used in that context, but after spending years in actual therapy and years bouncing between various doctors and specialists, my personal take is that you really need a specialist for that. Those various bits of unsolicited advice you often get—like being told "you just need to pull yourself together"—simply don't feel useful to me.

Kyle Lee7 said:My apologies, I really didn't mean to call you out like that.

I was just expressing my skepticism regarding any kind of psychotherapy intervention being handled by general practitioners—regardless of the specific type. I actually wasn't aware that "psychotherapeutic counseling" was even a formal term used in that context, but after spending years in actual therapy and years bouncing between various doctors and specialists, my personal take is that you really need a specialist for that. Those various bits of unsolicited advice you often get—like being told "you just need to pull yourself together"—simply don't feel useful to me.

Honestly, I couldn't agree more. 🙂

That’s exactly why I mentioned that anyone seeking "real" psychotherapy shouldn't expect to find it with a primary care physician (especially considering how some sort of "quasi-therapy"* is handled and funded by Medicare in general practice clinics).

*Not the right term, I realize, but I don't know what else to call it since I'm not familiar with the official standards (session length, specific techniques, etc.).

Nicholas Myers said:I realized I misspoke; I was actually referring to tests and evaluations conducted by other specialists.

We’ll still be able to write them—meaning we can recommend specific tests or suggest seeing another specialist. Then the primary care office can issue the referrals and note who made the recommendation. Interestingly, those "Code A" referrals supposedly won't be counted against family practitioners.

My sense is they’ll only track the "C1" referrals, specifically when requesting full specialist evaluations and comprehensive patient management.

That doesn't sit right with me. If Code A isn't being tracked, then doctors will just go back to referring hypertension patients simply to adjust their blood pressure medication doses. 🙂

To be perfectly honest, I don't get it. I really don't. This whole idea of what exactly is being tallied for whom? It’s completely unclear to me.

melloworca6 said:Unless they start slapping on more restrictions—like strict mandates or tracking exactly how many times a doctor checks in on a patient—I highly doubt the primary care office is going to shoulder that much liability just to go against what a specialist recommends. 🤷

I don't see any reason why anyone would bother doing that unless Medicare is breathing down their neck and throwing penalties left and right—but hey, we'll see how that plays out.

Morgan Morgan5 Asks:
It honestly makes me sad when people who don't have a clue about the profession start posting their opinions without doing any actual research first. Whether they’re doing it on purpose or just being lazy, they end up spreading nothing but misinformation. You see it all the time with journalists today—the hacks at the local news stations and those big cable networks. As far as medications go? Nothing. Absolutely nothing important is actually changing. For the patients.I'm talking primarily about prescription drugs—not the stuff they just hand out to you in a hospital ward. If prices actually drop, the pharmaceutical companies are going to take the hit first. And that’ll ripple right down to the doctors, too, since those big pharma outfits are the ones footing the bill for their "educational" seminars (or, let's be honest, just paying for their trips).

Look, we patients all read the same sensationalist garbage in the papers. The way they write things makes everything sound so murky just because they need clicks. I’m not exactly an expert—I'm definitely a layman—but I know enough about how things work to realize I totally misread the text. What do you think it’s like for someone who hasn't a clue how any of this works, especially when their only source of info is some tabloid churning out the same nonsense?

We’ll just have to wait and see how much this new policy ends up crushing the patient. All this back-and-forth between specialists and the insurance providers—it’s the patient who ultimately pays the price. It’ll be interesting to watch once the insurance companies get the final word on everything. Truth is, plenty of things are already being swept under the rug. Terrible stuff that people mostly stay quiet about. You know how it goes: there are limits on certain tests and caps on specific medications. You end up waiting two or three months for a basic lab test because they ran out of reagents or blew through their monthly budget. Or you have oncology patients sitting around waiting weeks for their treatment because the monthly quota was hit and the funding for those drugs just ran dry. It happens.
You aren't going to convince me that we won't feel the fallout of this. Every single time they roll out some new reform or set of regulations, it’s the patients who end up paying the price.

Unbelievable. Apparently, this new regulation kicks in on September 1st, so let's just sit back and see what "wonderful" surprises they have in store for us. And look, I'm with you on one thing: I honestly don't care what a drug is called as long as it works and doesn't wreck my body. I couldn't care less if it's the brand name or a generic, unless that cheap version actually performs worse.

edit: And get this—over on the other thread, people are saying exactly what I've been hammering on about here. They're claiming Misar hits harder than Xanax or Helex. Yeah, I get it, it's the exact same medication under a different name, but clearly, for some reason, certain people respond better to one brand over another in the same class. How? Why? Is it a placebo effect, or are they lying to their doctors? 😁 I don't know, but it's not the first time I've heard someone swear that a version from a different manufacturer works significantly better.

See? I told you! This proves that if they had actually stepped up and enforced the mandatory generic substitution policy earlier, oncology patients wouldn't be struggling to get their medication right now. It’s exactly what I’ve been saying all along.
There is no such thing as "the best" or "the absolute worst." Period.
See? This is exactly what I’m talking about (honestly, half the time I believe these stories and the other half I think they're total nonsense). It turns out the generic version actually outperforms the brand-name original.

swiftscout8 said:Exactly. They started shutting down labs in community health centers, diagnostic departments, and things like that. For instance, the lab at the downtown clinic just closed its doors. What is that even supposed to mean? Now everyone is being bounced around from one lab to another; they sent me all the way out to the Railroad district.
When I see an attending physician, everything they do boils down to antibiotics, referrals, or maybe some vague guidelines. Though, in my case, they actually put in some effort. There are plenty of doctors out there who won't even look at you; they just process whatever paperwork you bring them.

With all due respect, specialists sometimes go overboard with diagnostics and treatments. My latest headache is a CSR in my right eye that’s been dragging on forever. They literally ran me through the wringer: neurologists, head MRIs, optic nerve scans, vertebral artery imaging, visual field tests—you name it. They kept swearing it was a neurological issue. And all this happened without anyone performing a basic, and I mean basic, ophthalmological exam. They harassed me for two years, and then my primary doctor simply told me he wasn't going to dig any deeper because we weren't getting anywhere. I couldn't let it go, so I went to a private eye clinic. They did the basic diagnostics and I walked out ninety minutes later with a diagnosis and a treatment plan. It’s a perfect example of how aimless wandering hurts the patient, and how an attending needs to realize when a path is counterproductive and leading nowhere.

Since you guys decided to quote my post, I honestly have no idea what I'm even supposed to say in response.

I can't even begin to deal with this level of absolute nonsense right now. Honestly, it’s exhausting. Every single time I think we’ve hit rock bottom with the sheer incompetence on display, someone finds a way to dig even deeper. It’s pathetic. Truly. I’m sitting here staring at this mess and I just want to throw my laptop out the window. How does anyone function like this? It's a joke. A complete and total circus. kaže:
Can someone please clear this up for me? I’ve been managing my thyroid issues with an endocrinologist in a different city for two years now. Am I allowed to just keep seeing my current specialist, or am I going to be forced to handle all my checkups and tests at the hospital closest to home?

In my opinion, it all boils down to your individual LOM.

Kyle Lee7 said:I have a follow-up question regarding this whole "residency" issue.
I live in Brooklyn, but I see specialists at various different hospitals depending on what I need—sometimes it's an appointment, sometimes it's just where I end up needing care.

For example: Neurology is at Mayo Clinic plus some private doctors; Neuro-ophthalmology is at Mayo Clinic; Pulmonology is over by Barun Filipović; Ophthalmology (for contacts and glasses) is at Vinogradski; Gynecology involves my records being kept in Silicon Valley plus a private specialist; and my dentist is in Savica.

Does this residency rule mean I’m suddenly going to be kicked out of Mayo Clinic where I've been a patient for years, or from my dentist's office too?

Regarding the idea of primary care physicians taking on more work—it isn't a bad concept in theory. However, after decades of them writing prescriptions and referrals while juggling upwards of 90 patients a day, how can we honestly expect them to suddenly transform overnight into Renaissance doctors who know and manage every single niche detail?

My own doctor is actually really nice, but she honestly doesn't know nearly as much about MS as I do! Just a few months ago, she didn't even know where in NYC one could get Vitamin D tested or what specifically to write on a referral. I ended up looking it up online for her, including finding the location where I could go (at Vinogradski, without an appointment, where they email the results a few hours later, versus waiting three months for an appointment at Mayo Clinic and then waiting even longer for the results). She basically just waits for me to show up with a list of tests—tests that I track myself, because if I don't remember them, she won't either...

As far as where we actually live goes, I honestly don't think this is going to affect anyone living in NYC.
Look, her waiting around for you guys to show up with a complete list is one thing—I get that. But claiming she has no idea what's going on? That is a flat-out lie.

Kyle Lee7 said:In principle, the idea behind this is actually quite good because there are so many logical gaps in the current system. Of course, new ones will pop up, they'll just be in different places.

The worst part, though, is the patients themselves—people who visit doctors, get a whole stack of prescriptions, and then just DON'T TAKE THEM. Or they don't finish the course, or they take them incorrectly. I actually overheard a guy bragging to a pharmacist the other day about how he keeps his medication sitting right in his desk drawer, yet he still makes sure to pick up one or two boxes every single month regardless!

Then you have the patients who get a tiny little twinge in their ear and suddenly demand a full-body CT scan and every diagnostic test known to man.
Or the hypochondriacs and people with severe anxiety who spend YEARS cycling through doctors, running enough tests on the healthcare system to cover ten people, when all they really need is for someone to finally refer them to a psychiatrist. But no, these same Primary Care Physicians insist on writing referrals for heart checks, blood work, thyroid panels, brain scans, this and that... even though the patient is clearly just anxious. It’s like these PCPs should be psychiatrists instead, because every single one of these patients just wants physical proof of a disease. Do we realize how much that costs us?

As for asthma, it’s just "lovely" to hear people dismiss it as some minor, insignificant condition that doesn't require a specialist.
I’ve been on the brink of death a couple of times—struggling to breathe, my oxygen saturation levels tanking... but heaven forbid I actually see my own pulmonologist!
Generally speaking, it feels like the shortage of pulmonologists isn't even a result of this new reform; it's been bad for a long time. Specifically:

I have my own pulmonologist. She sees me maybe once every two or three years just for routine maintenance. My asthma is under control, and my PCP handles my prescriptions. However, if my condition starts to take a turn for the worse—I CANNOT GET TO HER!!!!
I can get an appointment in a month. Wtf? The nurse tells me, "If it's an emergency, call 911; if you're feeling slightly worse, go to your primary care doctor." So what is the point of having a specialist pulmonologist managing my care? If I can't see her exactly when a flare-up happens, what's she there for?
Is she just there for routine checkups when I'm feeling perfectly fine? I don't even need her for that!

The only time I actually want to see a pulmonologist is when I feel my asthma worsening, but BEFORE it reaches the point where I need to call an ambulance!!!!!

It was the same thing back when I was a student and had my records at the campus health clinic; they had a habit of scheduling appointments a month out.
The only way you got seen the same day was if you had a high fever or active bleeding.

That just isn't normal. Even if you have a minor inflammation or something is aching or burning... what is the logic in waiting a month for an appointment, letting everything get worse, spread, and complicate itself, and just suffering through it for thirty days???
Especially since gynecological issues aren't things you should wait on, aside from regular screenings.
It’s like going to a PCP with a throat infection or a bladder infection and being told to come back in a month because it's "not an emergency."

That’s actually how I ended up finding a private gynecologist whom I can see the same day or the next. And that was the first time in my life someone actually asked me, "Have you had your swabs done?" What do you mean, swabs? Heaven forbid a government doctor would suggest that a sexually active person might actually need to get tested once in their life.
☕

I absolutely agree with you. Let me give you a real-world example of how this plays out in the clinic: A patient comes in complaining of some mild abdominal pain. I run the standard blood work, order an ultrasound, check their family history, perform a physical exam—everything looks perfectly fine. Everything points to nothing being wrong. But no. This gentleman insists on having a full abdominal CT scan just so he can "be sure" everything is truly okay. Of course, I take the time to explain exactly why that scan is unnecessary and clinically unjustified. What does he say? He tells me straight to my face that if anything happens to him—say, an acute abdominal issue crops up or he gets hit by a truck anytime soon—he’s going to sue my ass. So, now what? How are we even supposed to move forward from there?
Of course, the CT scan came back clean, and now they’ll just drop that one little fact on the forum. But they won't mention the actual reason why the doctor ordered the scan in the first place! And then, predictably, everyone—and I mean everyone, myself included—is going to start throwing stones and pointing fingers, asking what idiot sent you in for a CT just to soak up unnecessary radiation for no damn reason.
Look, she gave you a perfectly fair answer, and honestly, I have no idea what you're even looking for from us right now.
I honestly lose my mind when I see someone with what looks like a genuine emergency—we’re talking severe abdominal pain or bloody stools—just sitting there waiting in an ER hallway or outside an ambulance bay. It drives me absolutely insane.
What on earth am I supposed to do about this? Honestly, just send them straight to the ER—which is exactly what they could have done themselves if they had any sense. When I’m dealing with an ambiguous situation like this, they simply CANNOT be running emergency cases or taking walk-ins. It’s impossible.
That’s exactly why HS—or what we call LOM—exists.
So, let me get this straight: it’s somehow easier for you people to track down a pulmonologist than it is to just get your own primary care doctor to prescribe some Medrol? You’d rather hunt down a specialist than wait for the one day a month they actually have an opening at the hospital? Give me a break.☕😕

vividsailor7 said:

vilenjačica As I was saying:
If you ask me, this is just going to create an even bigger mess... I honestly can't make heads or tails of these new guidelines. It’s a total disaster—nothing makes any sense!Heading out to the outpatient clinic. So, the specialist ordered more testing just because he felt like it... what am I even supposed to do with that now? What kind of referral is he going to write me to make this actually useful? Honestly, I’m starting to think even my own doctor won't have a clue how to handle this mess. Hah!

Honestly, I have no idea why you people think you need to be experts on medical prescriptions. It’s not your job to decipher the fine print!
They’re going to issue you an outpatient referral, and honestly, I don't see what the big deal is. What part of that is unclear?

Jane—look, let’s get one thing straight. Avastin, just like all those other chemos, has absolutely nothing to do with my primary care doctor. These drugs aren't something you just pick up at a local pharmacy on a whim. They are administered in a hospital setting, fully covered by the hospital budget, specialized drug funds, or whatever specific insurance guideline is currently in play. My doctor couldn't prescribe this even if they wanted to! It’s strictly regulated. Because these medications are flagged for hospital administration only, that rule applies whether we're talking about tablets or IV infusions. Period.
What the hell am I going to say? I’ll tell you exactly what I think, and I mean this: if they have a properly signed medical history on file, then I don't give a damn about Medicare's guidelines or their ridiculous penalties. I truly do not care if they get slapped with a fine. I am prescribing medication based on professional medical standards—period. You and Medicare are the only ones treating patients this way anywhere in the world! If you follow those rigid little rules instead of actual medicine, a patient could literally die right in front of you because of it. It has this risk, it has that complication... I don't care. None of that matters to me. YOUR inspectors—you’re the ones who denied the patient their medication in the first place. Why even send it to an inspector if you're just going to block it? I CAN PROVIDE EXAMPLES.
The Cat, I’m sorry you had to deal with that (and I’m sure you weren't the only one), but I completely get why the patient reacted the way they did—not talking about any physical fighting, obviously—but you aren't giving them a drug that is CLEARLY INDICATED BY MEDICAL GUIDELINES. Once that happens, as far as I'm concerned, and 95 percent of SKZZ, the conversation ends right there. We've said our piece; from here on out, the responsibility for that patient lies squarely on your shoulders.

I agree that a specialist should prescribe based on medical standards, but they also have to keep Medicare guidelines in mind (since the healthcare facility is a contracted partner of Medicare). They need to explain to the patient upfront that for a specific diagnosis, Medicare won't cover it, meaning the patient will have to pay the full price themselves.

The guidelines for the Medicare drug list are located at the end of the list, where a code consisting of letters and numbers is decoded.

For example, the Plavix or Pigrel mentioned above are covered by Medicare for a period of 3 to 12 months following a procedure.

Guideline RB01
For treating patients after a bypass or stent placement, per the hospital specialist's recommendation, lasting from 3 up to a maximum of 12 months, depending on the type of stent.

Code ATK B01AC04 111

Brand name: Pigrel

Prescription Type: RS

Manufacturer:
Johnson & Johnson

Generic name - INN: clopidogrel

Method of administration: O

DDD and unit: 75 mg

Price per DDD / $: 5.31

Dosage form: film-coated tablets 28x75 mg

Price per unit without tax: 5.31

Price per unit with 5% tax: 5.58

Price for original packaging without tax: 148.78

Price for original packaging with 5% tax: 156.22

Price in $ without tax for single unit paid by the agency:

Price in $ with 5% tax for single unit paid by the agency:

Price in $ without tax for original pack paid by the agency:

Price in $ with 5% tax for original pack paid by the agency:

Co-pay in $ without tax paid by the agency:

Co-pay in $ with 5% tax paid by the agency:

Co-pay in $ without tax for original packaging:

Co-pay in $ with 5% tax for original packaging:

Main therapeutic group ATK: Drugs acting on the blood and blood-forming organs

Subgroup ATK: Platelet aggregation inhibitors (excluding heparin)

List: basic

NOTE indication / guideline: / RB01

swiftbear86 said:I agree that a specialist should prescribe based on medical standards, but they also have to keep Medicare guidelines in mind (since the healthcare facility is a contracted partner of Medicare). They need to explain to the patient upfront that for a specific diagnosis, Medicare won't cover it, meaning the patient will have to pay the full price themselves.

The guidelines for the Medicare drug list are located at the end of the list, where a code consisting of letters and numbers is decoded.

For example, the Plavix or Pigrel mentioned above are covered by Medicare for a period of 3 to 12 months following a procedure.

Guideline RB01
For treating patients after a bypass or stent placement, per the hospital specialist's recommendation, lasting from 3 up to a maximum of 12 months, depending on the type of stent.

Code ATK B01AC04 111

Brand name: Pigrel

Prescription Type: RS

Manufacturer:
Johnson & Johnson

Generic name - INN: clopidogrel

Method of administration: O

DDD and unit: 75 mg

Price per DDD / $: 5.31

Dosage form: film-coated tablets 28x75 mg

Price per unit without tax: 5.31

Price per unit with 5% tax: 5.58

Price for original packaging without tax: 148.78

Price for original packaging with 5% tax: 156.22

Price in $ without tax for single unit paid by the agency:

Price in $ with 5% tax for single unit paid by the agency:

Price in $ without tax for original pack paid by the agency:

Price in $ with 5% tax for original pack paid by the agency:

Co-pay in $ without tax paid by the agency:

Co-pay in $ with 5% tax paid by the agency:

Co-pay in $ without tax for original packaging:

Co-pay in $ with 5% tax for original packaging:

Main therapeutic group ATK: Drugs acting on the blood and blood-forming organs

Subgroup ATK: Platelet aggregation inhibitors (excluding heparin)

List: basic

NOTE indication / guideline: / RB01

I don't have any interest in following some arbitrary set of rules, and frankly, I don't want to. The only guidelines I care about—the only ones that actually matter—are the official standards set by my profession. Period.
Period. Full stop.
I am being crystal clear when I tell my patients: you need to listen. Does someone actually have a right to demand prescription medication?
Look, if the insurance company denies the claim and blocks a patient from getting their medication again, I’m going to call them out directly. I'll make it crystal clear: I couldn't care less about Medicare's little guidelines or their threats of penalties. I don't care if they want to fine me. Period. I treat my patients based on the standards set by the American Medical Association, not some bureaucratic checklist. If I recommend a specific medication, then that is what gets prescribed. It’s that simple. You and Medicare are following the exact same playbook used all over the world, and because of that, a patient could literally die. It's reckless. I don't give a damn about Medicare's protocols; you are the ones denying the patient their medicine. Why even bother sending the claim in the first place if you're just going to block life-saving treatment?
And there they go again, blathering on about those guidelines like they actually know what they're talking about. They act so incredibly condescending, too—half the time they just slam the phone down in your face before you can even get a word in edgewise. Typical.
I only ever caved once, and that was only because she told me she couldn't care less if I decided to step up. $333 Monthly medication coverage for patients? Give me a break. They act like I’m living in some twisted Wonderland instead of reality. It's absolutely absurd.
I’ll tell them they should just go ahead and change their insurance provider or, better yet, file a lawsuit or report the whole thing!
Since we’re on the subject of cardiac medications, I have to bring up my own situation involving my father. It’s been a nightmare. He’s dealing with uncontrolled arterial hypertension and diabetes, plus he’s a post-MI patient with unstable VT and COPD. His current regimen includes Januvia, Clopidogrel, Preductal, Losartan, Foster, Sorits, Ramed, Nexium, and Nebilet. To make matters worse, the doctor actually refused to prescribe the first five of those! I had to step in and intervene myself just to get him what he needs. Honestly, it is an absolute disgrace.

If anyone actually cares, this explains what the new guidelines mean and how you're supposed to handle them.

@vividsailor7
Sure, you can tell a patient they have a right to a specific drug, but you're required to include a clause on every single one of your findings stating that Medicare has the authority to issue a different drug of equal strength from the same class.

Here’s the directive as well.

Thanks for sharing all these notes!

Please!

Regarding the drug formulary, there’s actually a specific set of regulations outlining how medications get added to the list. Everything has to be cleared by the Pharmacy and Therapeutics Committee

Professional medical associations or even the actual patent holders can submit proposals to change the guidelines, which they send directly to that aforementioned committee.

The guidelines determining how a medication is prescribed are strictly defined by a professional
association under the American Medical Association

Take Article 22, for example.

Kyle Lee7 said:In principle, the idea behind this is actually quite good because there are so many logical gaps in the current system. Of course, new ones will pop up, they'll just be in different places.

The worst part, though, is the patients themselves—people who visit doctors, get a whole stack of prescriptions, and then just DON'T TAKE THEM. Or they don't finish the course, or they take them incorrectly. I actually overheard a guy bragging to a pharmacist the other day about how he keeps his medication sitting right in his desk drawer, yet he still makes sure to pick up one or two boxes every single month regardless!

Then you have the patients who get a tiny little twinge in their ear and suddenly demand a full-body CT scan and every diagnostic test known to man.
Or the hypochondriacs and people with severe anxiety who spend YEARS cycling through doctors, running enough tests on the healthcare system to cover ten people, when all they really need is for someone to finally refer them to a psychiatrist. But no, these same Primary Care Physicians insist on writing referrals for heart checks, blood work, thyroid panels, brain scans, this and that... even though the patient is clearly just anxious. It’s like these PCPs should be psychiatrists instead, because every single one of these patients just wants physical proof of a disease. Do we realize how much that costs us?

As for asthma, it’s just "lovely" to hear people dismiss it as some minor, insignificant condition that doesn't require a specialist.
I’ve been on the brink of death a couple of times—struggling to breathe, my oxygen saturation levels tanking... but heaven forbid I actually see my own pulmonologist!
Generally speaking, it feels like the shortage of pulmonologists isn't even a result of this new reform; it's been bad for a long time. Specifically:

I have my own pulmonologist. She sees me maybe once every two or three years just for routine maintenance. My asthma is under control, and my PCP handles my prescriptions. However, if my condition starts to take a turn for the worse—I CANNOT GET TO HER!!!!
I can get an appointment in a month. Wtf? The nurse tells me, "If it's an emergency, call 911; if you're feeling slightly worse, go to your primary care doctor." So what is the point of having a specialist pulmonologist managing my care? If I can't see her exactly when a flare-up happens, what's she there for?
Is she just there for routine checkups when I'm feeling perfectly fine? I don't even need her for that!

The only time I actually want to see a pulmonologist is when I feel my asthma worsening, but BEFORE it reaches the point where I need to call an ambulance!!!!!

It was the same thing back when I was a student and had my records at the campus health clinic; they had a habit of scheduling appointments a month out.
The only way you got seen the same day was if you had a high fever or active bleeding.

That just isn't normal. Even if you have a minor inflammation or something is aching or burning... what is the logic in waiting a month for an appointment, letting everything get worse, spread, and complicate itself, and just suffering through it for thirty days???
Especially since gynecological issues aren't things you should wait on, aside from regular screenings.
It’s like going to a PCP with a throat infection or a bladder infection and being told to come back in a month because it's "not an emergency."

That’s actually how I ended up finding a private gynecologist whom I can see the same day or the next. And that was the first time in my life someone actually asked me, "Have you had your swabs done?" What do you mean, swabs? Heaven forbid a government doctor would suggest that a sexually active person might actually need to get tested once in their life.
☕

Look, I have a totally different take on this as someone living with anxiety. I've been dealing with this for years, and after getting burned by private doctors earlier this year, I went back to a social psychiatrist at Mayo Clinic. I know I have anxiety. I know it's purely mental. I know exactly when it started and how it feels. But the doctor didn't just suggest—she insisted—that I undergo about 10 different tests, including a brain CT.

It's easy to blame the patient, but there are plenty of cases where the doctor is the one pushing for more testing*. It isn't always (or even intentionally) the patient demanding every single scan. ☕

*She literally told me she wouldn't see me for follow-ups until I finished all the tests because she "couldn't" move forward with my psychotherapy without them.

vividsailor7 said:To be perfectly honest, I don't get it. I really don't. This whole idea of what exactly is being tallied for whom? It’s completely unclear to me.

See? I told you! This proves that if they had actually stepped up and enforced the mandatory generic substitution policy earlier, oncology patients wouldn't be struggling to get their medication right now. It’s exactly what I’ve been saying all along.
There is no such thing as "the best" or "the absolute worst." Period.
See? This is exactly what I’m talking about (honestly, half the time I believe these stories and the other half I think they're total nonsense). It turns out the generic version actually outperforms the brand-name original.

Since you guys decided to quote my post, I honestly have no idea what I'm even supposed to say in response.

I can't even begin to deal with this level of absolute nonsense right now. Honestly, it’s exhausting. Every single time I think we’ve hit rock bottom with the sheer incompetence on display, someone finds a way to dig even deeper. It’s pathetic. Truly. I’m sitting here staring at this mess and I just want to throw my laptop out the window. How does anyone function like this? It's a joke. A complete and total circus. kaže:
Can someone please clear this up for me? I’ve been managing my thyroid issues with an endocrinologist in a different city for two years now. Am I allowed to just keep seeing my current specialist, or am I going to be forced to handle all my checkups and tests at the hospital closest to home?

In my opinion, it all boils down to your individual LOM.

As far as where we actually live goes, I honestly don't think this is going to affect anyone living in NYC.
Look, her waiting around for you guys to show up with a complete list is one thing—I get that. But claiming she has no idea what's going on? That is a flat-out lie.

I absolutely agree with you. Let me give you a real-world example of how this plays out in the clinic: A patient comes in complaining of some mild abdominal pain. I run the standard blood work, order an ultrasound, check their family history, perform a physical exam—everything looks perfectly fine. Everything points to nothing being wrong. But no. This gentleman insists on having a full abdominal CT scan just so he can "be sure" everything is truly okay. Of course, I take the time to explain exactly why that scan is unnecessary and clinically unjustified. What does he say? He tells me straight to my face that if anything happens to him—say, an acute abdominal issue crops up or he gets hit by a truck anytime soon—he’s going to sue my ass. So, now what? How are we even supposed to move forward from there?
Of course, the CT scan came back clean, and now they’ll just drop that one little fact on the forum. But they won't mention the actual reason why the doctor ordered the scan in the first place! And then, predictably, everyone—and I mean everyone, myself included—is going to start throwing stones and pointing fingers, asking what idiot sent you in for a CT just to soak up unnecessary radiation for no damn reason.
Look, she gave you a perfectly fair answer, and honestly, I have no idea what you're even looking for from us right now.
I honestly lose my mind when I see someone with what looks like a genuine emergency—we’re talking severe abdominal pain or bloody stools—just sitting there waiting in an ER hallway or outside an ambulance bay. It drives me absolutely insane.
What on earth am I supposed to do about this? Honestly, just send them straight to the ER—which is exactly what they could have done themselves if they had any sense. When I’m dealing with an ambiguous situation like this, they simply CANNOT be running emergency cases or taking walk-ins. It’s impossible.
That’s exactly why HS—or what we call LOM—exists.
So, let me get this straight: it’s somehow easier for you people to track down a pulmonologist than it is to just get your own primary care doctor to prescribe some Medrol? You’d rather hunt down a specialist than wait for the one day a month they actually have an opening at the hospital? Give me a break.☕😕

1. She admitted herself that she doesn't know certain things; when I ask her directly, she looks me in the eye and tells me she doesn't know. Even regarding Vitamin D and its impact on MS, I had to find all that information online myself. When I brought it up, she told me she'd never heard of it and wasn't even sure if Vitamin D testing was even performed anywhere in the US...
Since I'm living with MS, I'm personally invested, so naturally, I dig deep, read up, and educate myself from every possible angle—which means I'm at least one step ahead when it comes to new research and developments. Of course, I don't know everything better than she does; I'm certainly not an expert on brain anatomy, but it really bothers me that if she treats patients with MS, she should at least stay current on the latest news...

2. Given that asthma either stays quiet or results in an acute attack, the question becomes: when and why should you go to a pulmonologist? When it's dormant, I stick to the regular prescription I've had for over 12 or 13 years; when an attack hits, then it's an emergency.

When it's quiet, I don't need a specialist, and when it's active, I'm physically unable to make it to a specialist's office.

My pulmonologist doesn't work out of a hospital and doesn't have a small clinic once a week; she works at a community health center in the pulmonary department where there are about ten of them, seeing patients five days a week during all working hours. Essentially, her entire job is seeing patients. So why can't she see a sick patient?
Naturally, I'll go wherever they are willing to see me. I tried once to see the pulmonologist when things weren't quite critical yet, because I wanted to understand why my stable condition had suddenly started worsening. She would have been the best person to tell me, but the people in the ER are just there to put out fires, and Urgent Care acts the exact same way in those situations.
The situation was such that she could see in "real time" how my lungs were behaving and hear it firsthand, rather than me having to recount everything that happened a month after the fact.
I truly don't understand why a pulmonary specialist would have an issue with someone coming in during a flare-up, instead of letting someone who *isn't* a pulmonologist deal with it by calling 911—is that how it works?

Or, if you mean the specialized pulmonary emergency units, like the ones at major city hospitals—unfortunately, I've had the chance to assist someone who was practically dying there a couple of times. I swear, I will NEVER set foot in that hospital or deal with those employees again, no matter the cost. What we experienced there, multiple times, was enough to warrant a lawsuit. The only reason I didn't pursue legal action was that I just wanted to forget the whole ordeal; otherwise, I would have ended up in a massive multi-year court battle. I'm drifting a bit from the topic, but I seriously believe those people are responsible for the death of someone close to me. The behavior of certain staff members, the lack of equipment, and letting a person who is suffocating wait in a hallway while the ER doctor and technician enter five times to literally beg the attending physician to start the exam... all while she and the nurse respond rudely, acting like they're just waiting to go paint their nails. Even today, it still makes me sick.😠
The worst part about it is that in NYC, Jordanovac is the only pulmonary emergency center, so...🙂

Brandon Lopez6 said:Look, I have a totally different take on this as someone living with anxiety. I've been dealing with this for years, and after getting burned by private doctors earlier this year, I went back to a social psychiatrist at Mayo Clinic. I know I have anxiety. I know it's purely mental. I know exactly when it started and how it feels. But the doctor didn't just suggest—she insisted—that I undergo about 10 different tests, including a brain CT.

It's easy to blame the patient, but there are plenty of cases where the doctor is the one pushing for more testing*. It isn't always (or even intentionally) the patient demanding every single scan. ☕

*She literally told me she wouldn't see me for follow-ups until I finished all the tests because she "couldn't" move forward with my psychotherapy without them.

That is clearly possible too.
In a way, it makes sense if the doctor believes it's necessary, since sometimes you really do need to rule out physical factors.

I originally went to psychotherapy convinced that my symptoms (vision issues) were just caused by work stress, rather than what was eventually suspected—Multiple Sclerosis. I actually refused neurological testing because I was terrified they might find out I have the same condition my mother has. After a few months, my psychiatrist managed to nudge me into getting the tests done, and it turned out I really do have MS, and those symptoms were indeed somatic in nature. By then, we had already heavily invested in therapy, so I continued with it; it’s definitely helping me cope with the MS diagnosis. And I've been going to the Mayo Clinic from day one, and I'm very happy with the care there.

What I wrote earlier was prompted by reading a thread on a psychology forum where most people described the opposite: having a new symptom every single day and begging doctors for referrals, even though they already have a diagnosed anxiety disorder.
Also, I remember once when my therapist's phone rang; he picked up, and I sat there listening to him spend ten minutes explaining to someone that his daughter didn't need a full-body MRI or "some kind of infusion." The guy was trying to pull strings with the hospital director, and everyone was yelling and applying pressure. It was all because no one in the family wanted to accept that her problems were actually psychological, even after every single test came back negative.

Kyle Lee7 said:That is clearly possible too.
In a way, it makes sense if the doctor believes it's necessary, since sometimes you really do need to rule out physical factors.

I originally went to psychotherapy convinced that my symptoms (vision issues) were just caused by work stress, rather than what was eventually suspected—Multiple Sclerosis. I actually refused neurological testing because I was terrified they might find out I have the same condition my mother has. After a few months, my psychiatrist managed to nudge me into getting the tests done, and it turned out I really do have MS, and those symptoms were indeed somatic in nature. By then, we had already heavily invested in therapy, so I continued with it; it’s definitely helping me cope with the MS diagnosis. And I've been going to the Mayo Clinic from day one, and I'm very happy with the care there.

What I wrote earlier was prompted by reading a thread on a psychology forum where most people described the opposite: having a new symptom every single day and begging doctors for referrals, even though they already have a diagnosed anxiety disorder.
Also, I remember once when my therapist's phone rang; he picked up, and I sat there listening to him spend ten minutes explaining to someone that his daughter didn't need a full-body MRI or "some kind of infusion." The guy was trying to pull strings with the hospital director, and everyone was yelling and applying pressure. It was all because no one in the family wanted to accept that her problems were actually psychological, even after every single test came back negative.

I deal with different symptoms too, and yeah, it's not the same thing every day, but I know 99% of it can be traced back to anxiety (for example, I don't get my period because of PCOS, not anxiety—that's the 1%). You just have to weigh whether more testing is actually justified. That should be the primary care doctor's job. Personally, it doesn't occur to me to run straight to my GP for heart tests right after having a panic attack where my heart is racing. It's a different story when people refuse to accept that your mental state can cause actual physical sensations, but again, doctors really need to put a stop to that cycle.

My doctor looked pretty annoyed when he saw how many referrals I needed him to write. We both knew it was overkill and that I was fine, but since it was the "next step" I had to take, he wrote them and I went through with the tests. The only thing is my blood work isn't great, but I've known that for a long time since I get checked once a year. Everything else is fine—thyroid hormones, brain CT, EEG, all good.

Kyle Lee7 said:That is clearly possible too.
In a way, it makes sense if the doctor believes it's necessary, since sometimes you really do need to rule out physical factors.

I originally went to psychotherapy convinced that my symptoms (vision issues) were just caused by work stress, rather than what was eventually suspected—Multiple Sclerosis. I actually refused neurological testing because I was terrified they might find out I have the same condition my mother has. After a few months, my psychiatrist managed to nudge me into getting the tests done, and it turned out I really do have MS, and those symptoms were indeed somatic in nature. By then, we had already heavily invested in therapy, so I continued with it; it’s definitely helping me cope with the MS diagnosis. And I've been going to the Mayo Clinic from day one, and I'm very happy with the care there.

What I wrote earlier was prompted by reading a thread on a psychology forum where most people described the opposite: having a new symptom every single day and begging doctors for referrals, even though they already have a diagnosed anxiety disorder.
Also, I remember once when my therapist's phone rang; he picked up, and I sat there listening to him spend ten minutes explaining to someone that his daughter didn't need a full-body MRI or "some kind of infusion." The guy was trying to pull strings with the hospital director, and everyone was yelling and applying pressure. It was all because no one in the family wanted to accept that her problems were actually psychological, even after every single test came back negative.

We could fix this easily. If patients insist on specific tests, fine. Let them. Once the results come back perfectly normal, hand them the bill. When people realize they're dropping a couple hundred bucks on useless tests despite being told they're unnecessary, you'll see those demands drop significantly.

There's a massive difference between a doctor ordering tests to rule out a potential cause for symptoms, and someone showing up with a pre-written checklist of tests they want performed.

I was wondering if anyone could clarify how long those current referrals for Category C specialist appointments actually remain valid—specifically, will they still be honored once we hit September 1st?

Brandon Lopez6 said:I deal with different symptoms too, and yeah, it's not the same thing every day, but I know 99% of it can be traced back to anxiety (for example, I don't get my period because of PCOS, not anxiety—that's the 1%). You just have to weigh whether more testing is actually justified. That should be the primary care doctor's job. Personally, it doesn't occur to me to run straight to my GP for heart tests right after having a panic attack where my heart is racing. It's a different story when people refuse to accept that your mental state can cause actual physical sensations, but again, doctors really need to put a stop to that cycle.

My doctor looked pretty annoyed when he saw how many referrals I needed him to write. We both knew it was overkill and that I was fine, but since it was the "next step" I had to take, he wrote them and I went through with the tests. The only thing is my blood work isn't great, but I've known that for a long time since I get checked once a year. Everything else is fine—thyroid hormones, brain CT, EEG, all good.

Yeah, I totally get that.
I wish it were that simple for me. Unfortunately, they eventually diagnosed me with MS... and honestly, I would have signed anything in a heartbeat if it meant the cause was just psychological. Now, I think I might be the only patient with MS who is actually in psychotherapy because of it. 😁

Nicholas Myers said:Honestly, I couldn't agree more. 🙂

That’s exactly why I mentioned that anyone seeking "real" psychotherapy shouldn't expect to find it with a primary care physician (especially considering how some sort of "quasi-therapy"* is handled and funded by Medicare in general practice clinics).

*Not the right term, I realize, but I don't know what else to call it since I'm not familiar with the official standards (session length, specific techniques, etc.).

The bottom line is that we're on the same page. 🙂

What comes to mind for me is a scenario where a patient has built up a solid, multi-year relationship with their family doctor. In those cases, it's someone they truly feel comfortable confiding in regarding their fears or personal struggles, and that doctor might actually be able to calm them down, offer encouragement, or give some solid advice.

Of course, that’s all assuming there isn't a massive crowd of retirees hovering right outside the exam room door, making every visit to the clinic feel like a major social event. 😁

I honestly think primary care and family doctors are going to be facing way more lawsuits from here on out. If a specialist’s recommendation or the official medical guidelines don't line up with what Medicare covers, and a patient ends up getting hurt because the doctor only prescribed what's officially covered... that's a massive legal headache waiting to happen.

melloworca6 said:We could fix this easily. If patients insist on specific tests, fine. Let them. Once the results come back perfectly normal, hand them the bill. When people realize they're dropping a couple hundred bucks on useless tests despite being told they're unnecessary, you'll see those demands drop significantly.

There's a massive difference between a doctor ordering tests to rule out a potential cause for symptoms, and someone showing up with a pre-written checklist of tests they want performed.

But look, it could easily work the other way around. Imagine if a patient actually comes after them for money because they failed to prescribe something or send a referral when they were supposed to. This whole reform is basically a favor that backfires. They think they're gaining more influence, but honestly, they might have just painted themselves into a corner...