CMS doesn’t get it? Can they ever?

Katherine Rourke gets another gold star from me for her May 16 post, “Health IT Expenses Burden ACO Startups, But CMS Doesn’t Get It”.  I have this funny suspicion that there are a lot of things that CMS doesn’t get, and most of them involve marrying efficiency with smartly constructed programs.  As a provider who has decided to opt out of Medicare, part of what led me to make this decision were the inefficiencies involved in trying to work with a government-run program whose priorities do not include customer service.

A case in point is the new drug Prolia, used for treating osteoporosis and preventing potentially life-threatening fractures.  Yesterday, I found out that Medicare — unlike commercial insurance companies — does not authorize the use of specialty pharmacies, which can ship the drug to doctors and directly bill Medicare themselves.  Thus, I am forced to shell out around $850 for a single dose to be sent to me to give to the patient.  I then bill Medicare and hope all goes well and there are no delays with reimbursement.  Needless to say, I would be hard pressed to offer this therapy in the future to Medicare patients if I were continuing with it.

And what’s with calling an HMO established by CMS an ACO?  Is this just a clever ruse to diguise exactly what an HMO does?: keeps costs down by paying less and causing the patient to, thus, get less?  My old 8th grade high school teacher Ms. Rainey, bless her soul, used to have the most apt quips when we would come to her class every day.  And she was so right, again and again.  One morning, she told us the story of her son who bought a pair of sneakers at Payless Shoe Source.  In about two weeks, they were falling apart.  Her comment?   “Pay less, get less.”

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at