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Matthew Cortland, Esq πŸ–‹οΈ
This wasn’t an insurer, @Ocasio2018, the letter is from the transplant committee. And they're likely requiring a $10k reserve because of the significant out-of-pocket costs MEDICARE imposes on patients.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
Medicare has covered heart transplants since October of 1987, when HCFA Ruling 87-1 superseded HCFAR 80-1 which excluded heart transplants from Medicare coverage. [lgt pdf of Ruling No. 87-1]
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @SpectrumHealth
The letterhead indicates this is from Spectrum Health. is a non-profit healthcare system in Michigan. Lest there be any confusion over which division of Spectrum is at play, the signature block indicates this is the "Heart and Lung Specialized Care Clinics"
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
The letter also explicitly states the "multidisciplinary transplant committee" is making the decision. The transplant committee is a group of dedicated, interdisciplinary, medical professional who do not work for the payer, @Ocasio2018. So why'd they say no?
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
Immunosuppressive medications are absolutely necessary for a heart transplant recipient – immunosuppressants in this context are sometimes called "anti-rejection meds." Without them, the organ recipient's immune system would attack the donor heart, destroying it.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @UpToDate
But you don't need to take my word for it, Congresswoman-elect @Ocasio2018. This is the entry for "Induction and maintenance of immunosuppressive therapy in cardiac transplantation in adults" it's avail at
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
So we know, on the basis of the letter that: - it wasn't a payer rejecting the patient - it was a transplant committee - and they did so because of the out-of-pocket cost of immunosuppressants We don't know who the payer is.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
But we do know that if the patient isn't eligible for Medicare Part A on the date of the transplant, but is then, subsequently, covered by Medicare, that their meds would be covered under the Part D benefit (in other words, not under Part B). see, e.g.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
You might ask, would a heart transplant candidate be eligible for Medicare on the date of transplant but subsequently be eligible at a later date? Yes. That's why CMS and Medicare Learning Network have a "PROVIDER COMPLIANCE TIPS FOR IMMUNOSUPPRESSIVE DRUGS" fact sheet.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
And Part D imposes /significant/ out-of-pocket costs.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
The different permutations of Medicare possibilities here are quite complex. But assuming the patient doesn't qualify for Medicare on the basis of age (an assumption I'm making), the way they'd qualify for Medicare is on the basis of disability.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
But we make people wait 24 months after a disability determination before letting them access Medicare. That's how you could easily end up in the land of Part D coverage for immunusuppressants.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @TexasKidDoc
the amazing brings this to our attention, and this additional info, I want to add a couple of points: Medicare is doing this. Medicare is imposing astronomical out-of-pocket costs on this patient who is trying not to die. Medicare.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
This is not the fault of the transplant committee – it's Medicare. I'm a bioethicist, in this letter I too see a transplant committee with an ethical obligation to ensure that donor organs are not wasted trying to help the Medicare pt get a transplant
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
Some are blaming the institution, as if the $10k is for their pocket. No. It's for the cost sharing for anti-rejection meds that Medicare imposes on patients. This happens at Mayo, at Cleveland, at MGH. This happens all the goddamn time.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
This stuff isn't a secret conspiracy. This is from . Part B and Part D both impose significant out of pocket costs on transplant recipients.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
...do you have any idea how sick you need to be to get a heart transplant? Do you have any idea what being that sick _feels_ like? Patients can't go out and get a "side hustle" to fund these medication costs. Without the meds they'll reject the heart, they'll die.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
and, @Ocasio2018, my DMs are open, let's talk about health policy that serves everyone.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
I'm here for patients, I'm here for chronically ill folx, for disabled folx. The objective of my professional life, ever since a health insurance company tried to kill me, is fighting for a positive right to healthcare. The details are, quite literally, life and death for me.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
If you're new to my work, this thread ‡️ has a few short videos that will tell you why, as a chronically ill, disabled patient, healthcare matters so much to me.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @NewStatesman
If you'd prefer written pieces, in I wrote about the $141k in prescription medications it took to keep me alive last year:
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
And if you're wondering if I have first-hand experience navigating other impossible bureaucracies while desperately ill? The answer is, unfortunately, yes.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
I will not be used as a battering ram against @Ocasio2018. This stuff is incredibly complicated. To the extent the US healthcare 'system' is designed, it's designed to be complicated, it's designed to grind us down, it's designed to make us give up.
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
That's why this thread engaged in close textual analysis of the letter. That kind of close reading, coupled with substantial, in-depth, domain specific expertise is necessary to decipher this sort of healthcare communication. But reality doesn't fit the misogynistic narrative πŸ€·πŸ»β€β™‚οΈ
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Matthew Cortland, Esq πŸ–‹οΈ 24 Nov 18
Replying to @mattbc
Because, to be clear, I'm unequivocally rooting for @Ocasio2018 to succeed in advancing the cause of healthcare for all.
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Matthew Cortland, Esq πŸ–‹οΈ 25 Nov 18
Replying to @mattbc
Update: I've personally talked to the patient who received the letter from the transplant committee. They have successfully raised the $10k through GoFundMe to meet the transplant committee's requirement.
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