Featured Member
Gerald Podskalny, MD:
Teamwork and persistence pays off in Pennsylvania
By working together, Dr. Podskalny and his fellow physician advocates in Pennsylvania successfully improved access for patients receiving care under several Medicare policies that had previously restricted their access to approved treatments.
The Problem
In the spring of 2005, Medicare HGSA had no botulinum toxin type A (BOTOX®) coverage for hyperhidrosis (HH), dosing limits, and inadequate reimbursement for needle electromyography (EMG).
Action Taken
In May 2005, the carrier received information supporting differentiation of toxins and the need to include HH, reduce dose limits, and add proper EMG. But when new policies were published, none of the suggestions were included in the policy. In fact, HGSA had combined botulinum toxin type A and B policies, giving the drugs equal coverage.
Ten provider advocates, including two AfPA members - Dr. Gerald Podskalny and Dr. Mitchell Paulin - who serve as medical advisors to HGSA, wrote to the provider to express their concern. One of HGSA's Carrier Advisory Committee (CAC) members, who had not attended a CAC meeting in three years, shared a practice with Dr. Podskalny and asked him to attend the closed CAC meeting in his place. Dr. Podskalny attended the CAC meeting and went to battle for their patients requesting several policy changes.
The Result
Patients benefited from an improved HGSA policy that went into effect February 2006 and included:
- Differentiation for pediatric indications
- No dosage limits
- Coverage for hyperhidrosis and sialorrhea
- 14 new spasticity codes
What Worked
The high quantity and quality of physician advocates made all the difference in this case study. The more physicians who advocate for change, and the better their communication to key decision makers, the better chance they have of improving patient access to approved therapies. Providing physician advocates with training and hands-on assistance also contributed to the positive outcome. Dr. Podskalny felt well prepared because of the partnership he experienced and the information he received from the AfPA advisory board meeting in 2005.