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On the footprints of seroquel: closing the circle

Posted Mar 14 2011 3:46pm

If you watch CSI you know that the criminal always leaves some trace of his presence.  The scene is not the same.  This post takes a look at the “footprints of seroquel (and other atypicals).”

Many of the questions I asked in the previous post I still have no answer for.  But another set of questions seem really important:

  • The costs of virtually every medicaid program in the country is exploding. What keeps the whole process going? It seems obvious what pharmaceutical companies get out of it, but what about the other parties involved in keeping the system going?  What do insurance companies for example get out of it.  On the face of it it seems like the cost of medication would be a take away.  Any expense seems that way.  So what is the answer?

The reason is so obvious it is hard to see.  The MCO’s that run most medicaid programs make money off medication.  A friend helped me to see how.

  1. Medication is not the biggest ticket item that MCO’s must deal with.  Medication may cost $700-$800 a month.  Hospitalization even in a state hospital is $700 a day and sometimes much more.  Statistics say that 20% of people who are hospitalized are re-hospitalized within 30 days.  40% are rehospitalized within a year.  Last year Tennesse had 13,000 hospitalizations in state hospitals alone.  At 4-6 days a hospital stay the numbers are staggering.  In the eyes of MCO’s the biggest benefit of medication is that it keeps people out of the hospital. (By the way, I do not believe in this line of reasoning.  If it worked we would not be talking about the problem it is.  We cant afford to put people in the hospital, but yet we refuse to pay for the community resources they need. Medication is a poor substitute for a support system of people.)
  2. Medication defines the insurance companies definition of reality.  Mental illness is a medical problem that must be treated by medical people using medical means.  It defines the roles and relative importance of everyone in the system.  Most importantly it defines what you need to pay for and what is worth what.  One of the hugest problems affecting the survival of many services is that they simply dont pay very well.  Any provider or program that relies on medicaid reimbursement is finding out that reimbursement is shrinking and barely enough to meet pay-roll in many places.  The central role of medication defines what is necessary to pay for and what is elective or simply not worth as much.

There is another pay-off too.  It is the hardest to put your finger on.  It is also the one you want the most to not be true.  One friend calls it the “perverse financial motivation of insurance companies.”

If you are a medicaid mco the odds, at least in Tennessee, are that you are going to have 80-85% in “medical loss” (thats what you pay out).  The other 15% is administrative costs and profit.  The higher the level of need the more the state gives you to meet costs.  The more you get the higher your 15% is.  Insurance companies make money and drive medicaid costs higher and higher based on their acceptance of the questionable prescribing practices of too many doctors (more about that in later posts) and the unethical conduct of pharmaceutical companies in pushing for the use of medicines in ways they have no proven positive effect and pose a real danger to those who take it.  They make money on the medication prescribed as well as the diseases and illnesses that are secondary products of that medication.

I am not saying there is some Hollywood villain behind the scenes manipulating all this.  I am saying it is what has come to be and things that come to be that benefit all parties in some way continue to be done and are remarkably resistant to any effort to change them.  You only close the circle when you begin to understand how it benefits all those involved.

The only one it costs is us.  The things that drive medicaid costs drive money out of our pockets.  The reality is that we have come to pay for the diseases caused to a large segment of our population caused by the doctors who are trying to help them.  Do you feel like you have fallen through the looking glass?  I do.

Find out more about how these things affect you in your state.  Ask your legislators and public officials.  Someone needs to be answerable.  But that depends on us asking for answers.

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