Midwives of the Revolution

Explorations, analysis, and reflections on women's health, midwifery, and politics from a feminist, marxist lens


Leave a comment

Resisting a Dangerous Consequence of Privatizing Medicaid

As of July 1 this year, my state has adopted an HMO model for its Medicaid plans. All Medicaid members have been assigned a primary care provider in the network. Many members were bumped from the regular Medicaid onto one of the handful of private insurance companies this state’s Medicaid has contracted with. This will be a disaster for patients in loads of ways: private insurance is part of the problem with peoples’ access to healthcare in the United States. Those insurance companies and the underfunded state programs are really the only ones for whom this can be seen in any way as part of a solution. What a boon for Blue Cross Blue Shield, Humana, and a host of other for profit corporations that they now have millions more customers handed to them from state governments. 

As with all of the reforms packaged with the Affordable Care Act, I am waiting to see how it will all shake out. So far, however, I have noticed that a huge problem for patients is how difficult it is to navigate these plans. And from a provider standpoint, it is much more confusing. Where do we send our OB patients for ultrasound or to see a Maternal-Fetal Medicine specialist when their pregnancy is complicated? Well, it depends on their insurance. Whereas many area hospitals still accept regular Medicaid, many have decided not to contract with some of these new private Medicaid plans. So depending on the managed care plan you were assigned, you may have to travel farther to get care than previously. 

One plan in particular has been on my shit list for years. My clinic actually does have a contract with this company, so this is the first time I’ve seen up close how it operates — everywhere else I’ve worked or had a student rotation at didn’t take it. They used to do this direct marketing thing — set up a booth at the shopping mall or in the neighborhood and offer women diapers, coupons, and other incentives to get them to switch to their plan. The woman would sign up only to find that she now cannot go to the clinic where she already had established care. Luckily, this practice is no longer allowed, so in theory patients are signing up for more above-board reasons.

Their prescription drug coverage remains a reason for me to campaign against them. Regular Medicaid in my state is not perfect — but the drugs they cover actually make medical sense (though there are loads of gaps). Now, when prescribing, we have to look up the formulary for myriad private Medicaid plans. (And don’t get me started on the limitations of contraceptive coverage on regular or these private plans, even with the contraceptive mandate.) Insurance, not public health, is determining many of my medical treatments. This is not a rational healthcare delivery system.

injection medicationThe absolute tip of the iceberg for me, though, with privatized Medicaid, is the requirement for the provider or pharmacy to submit a prior authorization request when prescribing treatment for two conditions that I see pretty frequently: gonorrhea (which includes injection of a drug called ceftriaxone) and Pelvic Inflammatory Disease (PID) (which requires both ceftriaxone and 14 days of oral doxycycline). 

What is prior authorization? Basically, a road-block to getting my patient the necessary treatment immediately at the time of diagnosis. It means that either the pharmacy or I have to submit an form to the insurance company explaining my medical rationale for scripting this drug. We fax the request and then wait 24-48 hours for it to be approved. 

The request is invariably granted. They pay it. Then we have to get the patient back into the clinic pharmacy to pick up the medication, and in the case of ceftriaxone, to get an injection from clinical staff (it cannot be injected in the pharmacy). Some clinics get around this by stocking the medication themselves, but that is not an expense my clinic is able to take on.

These antibiotics are expensive, and should not be. But it is not as though we are throwing either around unnecessarily. Believe me, it is very important to not over-prescribe antibiotics. But is cost the only factor to consider in treatment? Don’t patients deserve to get appropriate treatment for infections that can have some pretty horrific consequences if not treated correctly

I believe that we who hold that healthcare is a right have a duty to work together to crack open the continuing gaps in the new healthcare systems and fight for one that includes everyone (and yes, that means including undocumented immigrants) and covers all basic healthcare as a human right. I plan on campaigning against privatized Medicaid, and this is just one example of how a for-profit corporation is putting their profits ahead of public health in that privatized system.

To that end, I wanted to share with you a letter that I sent to that private Medicaid contractor that requires prior authorization. I was fed up. And two weeks after sending it, I received a call from one of their representatives asking for more background on why I sent the letter. I’m not convinced this is the end of it, but I am happy to say that the representative reported to me that she would pass my concerns on to people [who I deduce are the company pharmacists] that make formulary decisions. 

If you are a healthcare provider dealing with this issue in your patient population, I heartily encourage you to pick up the phone and add your voice to the dissent. Or copy and paste elements of my letter and forward on to the insurance company that corresponds in your instance.

We are many. They need to hear from us.

 

***

Hello,

I am writing today because I am very concerned about the prior authorization requirement for medication ceftriaxone (Rocephin) and doxycycline. According to the Centers for Disease Control, a one-time injection of 250mg of ceftriaxone is the most appropriate treatment for gonorrhea (to be prescribed with azithromycin or equivalent). It is also the best treatment for pelvic inflammatory disease, along with 100mg oral doxycycline for 14 days.

As a women’s health provider, many patients present to my office with one or both of these conditions, requiring immediate treatment. Due to your organization’s prior authorization requirement for these medications, my [private corporation contracted] Medicaid patients face an unnecessary and potentially unsafe barrier when seeking treatment for these conditions. The prior authorization requirement means that complete treatment is delayed for these patients. I work in a setting for which transportation to the health clinic can be a significant issue – patients often report they delay seeking care due to economic and transportation barriers. It may not be easy for the patient to present to the clinic on a different day to pick up the prescription from the pharmacy and then receive the injection from our staff.

In addition to facing the stigma and emotional stress of having a sexually transmitted infection or PID, which can threaten a patient’s future fertility, this added barrier of delaying ceftriaxone treatment not only increases the emotional toll of such an infection – it also increases the threat of antibiotic resistance. If patients are not able to complete the full dose of the last remaining medication we have to treat gonorrhea, we could see an increase in resistance. Injection treatment for gonorrhea is supposed to help decrease antibiotic resistance. The prior authorization requirement runs the risk of making this an infection that can become even more threatening in not only the community I serve, but on a larger scale as well.

I am extremely concerned about the barrier that prior authorization requirement for these two medications creates for my patients, who deserve nothing less than safe and compassionate quality healthcare. I hope you will add ceftriaxone and 100mg doxycycline to the preferred drug list immediately, so we can enhance our patients’ access to care and improve public health.

Thank you for your attention to this matter. I look forward to hearing from you

Sincerely,

A Concerned Certified Nurse Midwife

Clinic X

Advertisements


Leave a comment

Clinical Resources for Providers & Patients

One of my major roles as a provider is to counsel patients about their health and link them with resources. I also spend a great deal of time educating myself about women’s health, since being a clinician requires lifelong learning — especially evident at the beginning of my career. I have compiled a pretty sweet resources list that I wanted to share, featuring legit, evidence-based sources that I trust.

I’ve arranged it by subject area and include a bit of info about its intended use. Enjoy, and please provide me with feedback — what works, what could be added, what’s maybe not so good.

Holistic Approaches Women’s Preventive Health & Primary Care

From the website: “Bright Futures for Women’s Health and Wellness implements and evaluates culturally competent, evidence-based consumer, provider, and community tools for women across their lifespan. Bright Futures for Women’s Health and Wellness materials help women of all ages achieve better physical, emotional, social, and spiritual health by encouraging healthy practices.” That side Includes resources on physical activity, nutrition, emotional wellness, and maternal wellness.

This is a great handout for patients developed by the Western Australian government’s public health department on sleep hygiene that I use often.

I post this visual aid developed by the Harvard Medical School in my exam rooms, to demonstrate a healthy food plate. It’s improved over the FDA’s food pyramid.

A good complement is this schematic of the Healthy Mind Platter, to demonstrate mental activities essential to mental health promotion.

Say what you will about the US Preventive Services Task Force (USPFT) — their resources are incredibly useful. This source walks you through the organization’s screening, counseling, and preventive medication recommendations.

This government site includes resources for patients and clinicians, including continuing medical education (CME) that midwives, other APNs, and docs might find useful. Topics include: CancerDiabetesGenitourinary ConditionsGynecologyHeart and Blood Vessel ConditionsMental HealthMuscle, Bone, and Joint Conditions, & Pregnancy and Childbirth

I really don’t know much about this organization, but what I’ve seen looks pretty great: Integrative Medicine for the Underserved provides community and resource-sharing for folks interested in this area.

Reproductive Health

CARDEAI recently learned about CARDEA by participating in an excellent series of CME events about providing care for transgender clients. They have lots of resources and offer training on a variety of topics you can peruse here. They seem to focus on reproductive health and “wraparound” services.

For STI prevention, treatment, and counseling, the CDC is tops. I have read the CDC’s STD Treatment Guidelines front to back more than once. If you provide any reproductive health services, it’s a must read. This is a library of resources straight from the CDC.

After you’ve done the CDC thing, I encourage you to hang out with the American Sexual Health Association. Their Herpes Resource Center is fantastic, but their overall positivASHAe and holistic approach to sexual health shines through everything they do. I’ve not used them, but they have brochures on STIs and other sexual health topics you can order for your clinic that look pretty good. And an intriguing book they recently published: Creating a Sexually Healthy Nation. Yes, please.

The National Chlamydia Coalition is seriously dedicated to our most common bacterial STI, chlamydia!

There isn’t any current medical consensus on the breast self-exam (BSE), but I still teach and encourage it, as it promotes awareness of the woman’s body. Here’s a link to a good teaching tool for the BSE.

I like this handout on kegel (pelvic floor or vaginal) exercises. Yay, vag workouts!

This is a comprehensive guide to female sexual health and wellness that everyone should read! It covers everything and is basically a course on female sexuality. Woot! Thanks again, ARHP!

General Clinical Practice

This Health Literacy Universal Precautions toolkit “offers primary care practices a way to assess their services for health literacy considerations, raise awareness of the entire staff, and work on specific areas.”

Cervical Cytology & Pathology (AKA Pap Stuff)

ASCCP_HeaderGraphicThe medical world hasn’t entirely caught up yet, but the American Society for Colposcopy & Cervical Pathology released its consensus guidelines on pap screening and followup a couple years ago. Hang out at their website to get the backstory and summary of screening and management guidelines.

OK, so this resource for clinics on managing HPV did get some funding from some pharmaceutical giants, but provides guidance on HPV management on a wide variety of issues/from different angles.

Family Planning & Abortion

For contraceptive prescribing, always start with the CDC. Here’s their Selected Practice Recommendations on Contraceptive Use. And don’t forget the Medical Eligibility Criteria.

My favorite new thing from the CDC. Highly recommended reading on providing comprehensive family planning services.

I am a proud member of the Association of Reproductive Health Professionals (ARHP)! Here is a page full of their patient fact sheets and patient resources on family planning.

The You Decide Toolkit is also from ARHP and “is designed to help health care providers better understand and speak to the risks and benefits of hormonal contraception.

The mama of all abortion resources is the National Abortion Federation. Their site can connect you with all the info you could ever want — from medical to political to funding issues.

RHAPThe Reproductive Health Access Project “seeks to ensure that women and teens at every socioeconomic level can readily obtain birth control and abortion from their own primary care clinician.” Their site has invaluable resources, from contraception info to miscarriage management to tools to help primary pare providers integrate comprehensive reproductive healthcare into their practice.

Backline, Connect & Breathe, and Exhale are all terrific organizations dedicated to providing options counseling and pro-choice, affirming post-abortion counseling.

Bedsider is a pretty hip, patient-centered site for helping people find the right birth control method.

It may not be the best place to work, but Planned Parenthood is still the best and biggest organization nationally providing evidence-based family planning services. Their site has lots of great health info.

The University of Chicago recently unveiled the guide Accessing Abortion in Illinois, which provides a very holistic approach “to help health and social service providers advise pregnant persons who may be seeking abortion care in Illinois.” Rad!

Pre-Conception & Fertility Promotion

CDC at it again — here’s a pretty old but still useful guide on improving preconception care as a public health concern.

Loads of stuff on planning pregnancy. March of Dimes has this stuff on their website on pregnancy planning, but no great stuff you can print (or integrate into your electronic medical record handouts).

I don’t know much about this organization, but Attain Fertility seems to have some good stuff for helping people get pregnant and info on IVF and fertility treatments.

I found this resource list that seems pretty comprehensive, including transgender parenting, same sex parents, and single parenting by choice. Nice!

Before & BeyondBefore, Between, and Beyond is “the national preconception curriculum and resource guide for clinicians.”

Every Woman California is a public health initiative in that state with resources on preconception heath that may be useful to folks in other areas.

Pregnancy

More goodness from the CDC. Links to pre-conception, contraception, pregnancy itselfpostpartum, and even basic infertility care and resources.

And from a different government agency (why are there so many?) through US Department of Health & Human Services, there’s this resource, with same topic areas covering pregnancy.

Childbirth ConnectionChildbirth Connection has almost 100 year old roots in being a resource for mamas in the US. This site is at a higher literacy level than many of my patients, so I mainly use this for my own reference on pregnancy, prenatal care, labor and birth issues, postpartum, and lactation. Others may find its utility as a direct patient resource. Fantastic, pro-woman, pro-midwifery organization and site.

Mother To Baby has a great collection of patient handouts on medication use in pregnancy that I frequently use. English & Spanish! They will also personally answer your clinical questions about drugs in pregnancy for stuff that’s not on the website. They also have evidence-based fact sheets on illicit drug use in pregnancy, but so far only cover three.

This is a patient worksheet you can use at the 6 week postpartum checkup, brought to you by our friends over at ARHP.

Woah! This app looks pretty cool — for mamas to trace embryonic and fetal development.

Some Sites for Continuing Medical Education

ARHQ sponsors some great, free, evidence-based CME activities on disease prevention and care management that you can find here.

More goodies from ARHP can be found in these Clinical Minute activities on family planning issues. They also have great webinars that may draw from their annual Reproductive Health conference content. As if that wasn’t enough, they also have CORE for additional repro health curricula.

Before, Between, & Beyond has CME on preconception topics.

Medications

I often use GoodRx.com to find drug discounts and coupons for uninsured patients. The site can text or email the coupon to the patient. You just have to find out which pharmacy they want to use.

Target and Walmart both have cheap generic medications available. If patient is uninsured, try to prescribe drugs off these lists and explain why you recommend filling the script at those stores.

ARHPedia_logoARHPedia (sound familiar?) is another source through ARHP: “the comprehensive source for resources on pharmaceutical products,” including coupons/samples/vouchers, patient education, patient assistance, and more.