Tuesday, December 26, 2023
Friday, December 22, 2023
Pro-bono Christmas Report Card Centered about Imperial Insurance of California by Keith Buster Torkelson MS
Feature Image
Title = “Human Autotroph”
(For the United States Department
of Agriculture and Dr. Schwabe)
Detective that is the Right
Question (I-Robot)
Pro-bono Christmas Report Card Centered
about Imperial Insurance of California by Keith Buster Torkelson MS
Auto Link
https://brandnewdayhmo.blogspot.com/2023/12/pro-bono-christmas-report-card-centered.html
2023 Pro-Bono Christmas Card Report
20231214-TH: Wrapping up the Marvel – SNG – Personal
Psychosis Crisis
Why do it Pro-Bono?
It would appear that SSDI will
cover the cost of this our annual Christmas Report Card. CMS gets an honorable mention.
Proposed Distribution
Like we said in the past we would
share in part or as a whole with many of the persons addressed in our Annual
Christmas Report Card. For this upcoming
term we will release this report in a whole form first via one of MSGs’ Blogs
and share once per month for the next twelve (12) months in 2024 around the
full moon as Peter Gabriel did with his I / O compilation.
Catharsis & Epiphone
20231222-F-Devin Velázquez Steve
for Chess (MIA)
Velázquez, also Velazquez,
Velásquez or Velasquez (/vəˈlæskɛz/, /-ˈlæz-/), is a surname from Spain. It is
a patronymic name, meaning "son of Velasco".
Warmline
OC Links
Dedicated Housing Help Line
Homeless Migration LA > OC
Blog
BND HMO
Performance Earned Value
The Save is up to Veronica
Kelley, Annette, Flor, Michelle, and
Executive Summary
We are pleased to announce that
this year’s Christmas Report Card focusing on the Doctors. The focal insurance partner is Imperial
Health Plan of California. As of 2023
Imperial replaces Universal Care Brand New Day as our Principle, Keith
Torkelsons, health insurer. In 2022 when
Brand New Days Plan H0838 was removed from the market they had earned
approximately 3.5 CMS Stars for their Overall score. Wheras, Imperial Health
Plan of California for 2023 earned 2.5.
During Buster’s shopping around for a plan to replace Univeral Care
Brand New Day he found it difficult to keep his current and relatively
long-term doctor Rimal B Bera MD. He
would have chosen SCAN over Imperial if they contracted with doctor RBB. CMS reported that Imperial was one of the
most challenged plans that they oversee in the United States. We have just been trying to help Imperial not
lose our Health Plan as did Brand New Day did at the end of 2022.
Time Spent about Intelligence
Our records indicate that in 2016
we began to formally develop Keith Torkelson’s Health Related Engagement
Concept (HRE). Basically, our HRE
addresses time spent in and around getting Buster the Healthcare Services
necessary to improve his health. Below
is a table with some HRE related Measures (Metrics).
Version for Imperial Driven Christmas Report Card
Health Related Engagements (HRE)
For Prosumer Keith “Buster” Torkelson MS (2022 & 2023)
“MHSA: The Good Fight”
Individuals and Groups
Combined in private healthcare
and public healthcare Torkelson transacts with more than twenty-five (25)
annually in the community. Here at Mentalation
Solution’s Group (MSG} our external Quality Review systems have grown
huge. So now on the cusp of 2023 / 2024
we sample our reports for priority reports.
Nations
For 2023 Imperial contracted with
a benefits bundle called OTC Nations.
The full package includes: Rewards monies, and Over-the-counter
allowance, and grocery. During 2022 BND had added a grocery allowance. A Torkelson lives with applied for Cal Fresh
and is awarded over $100 per month. Keith
applied through the Social Services Agency (SSA) process. He was hoping for $50 per month. His SSA worker delivered $21 per month. Keith is now relatively Buster. Buster is very grateful for his $21 per
month. On and off he uses to buy a steak
and dozen eggs. With this money Buster
ate a bit healthier.
Cast of Characters – Persons of
Interest (Including Feature Images)
Unfortunately this year we cannot
feature images of all in Buster’s Health Care Networks (HCNs). Buster basically has three (3) HCNs: Imperial-centered,
Orange County Health Care Agency (OCHCA), and his Natural Supports including
family and those providing for his living arrangements.
Brand New Day Lingerers -
Critical
Before 2012 Buster was aware of
BND because some of the people his lived with a Rent a Shared Room environment
had BND as their “Program”. During 2012
Buster ended up with BND. His first:
Worker, Helper, Care Coordinator, Life Coach, etc. Was Oswaldo Escalante. Oswaldo went the distance for Buster and in
doing so set a Worker Standard.. The
issue is when BND folded Buster’s insurance and the associated program is
Buster thought he would not have to see the under-performing Helpers
anymore. Imperial retains contract with
Central City Community Health Center (CCCHC).
And CCCHC decided to give the under-performing Helpers a job. So basically they hired the people who
contributed to BND’s failure.
Central City Community Health
Center (CCCHC)
Here we focus on clinic (CCCHC)
centered clerical and clinical. Buster
has been with CCCHC since 2012 and about many incarnations. For 2023 we offer people he deals with 5.0
Stars. This includes those that
participate in The client Clozapine Registry monthly Complete Blood Count (CBC)
process. The client wasn’t really happy
when CCCHC decided to swap out Quest Diagnostics for Labcorp. It took considerable effort on our part to
get Labcorp to bill correctly.
Dental – In Network
Dental is a global problem so the
issue with have with Imperial is not just centered around them. Our standard for superior dental is Universal
Care Dental. After BND disengaged
Universal Dental they went with Liberty and Delta Dental. Currently, Imperial
contracts with Liberty for its’ dental plan.
Liberty is not a plan synergistic with the dental needs of older
adults. They cover things that a child
or adolescent would need such as cleaning and fillings. Older adults need services such as:
Extractions, implants, dentures and the like.
So basically, older adults have to suffer pain because they cannot
afford services not covered or those that have extensive co-pays. Basically we score The client dental a needing
substantial improvement. If we could we
would get a picture of Patrick’s mess of a mouth.
Dentist out of Network [STAYED]
Psychiatry Evaluation
Since The client was first
prescribed a psychotropic back 1989 he has retained just over 17 psychiatrists. His best were Dr. David Dobos and some of the
low performers are: Dr. David Chandler, Daniels [?], De Silva, Himasiri K. and
Vu, Alan. Currently The client is served
by Dr. Rimal B Bera. After more than a
year into their partnership we here at MSG give RBB a PASS. One merit for RBB is that he has stepped up
his triage using medical students.
Bindra
Imperial_Vitals_Stars_23090203_Notes
A key player in The client’s new
health insurance, Imperial Health Plan of California, is Dr. Bindra. The client receives many documents in the
mail signed by Dr. Bindra. So when we
received the first of 3 Medicare Experience Surveys: First was paper version,
second was internet version and the third was another paper version. With Brand New Day Buster is the client. Was
assigned a Single Point Contact (SPC).
He would share BND mandated assessment result with her. She demonstrated that she valued Buster as a
concerned individual. In 2023 Buster
gave Dr. Bindra a chance to touch bases as he did back in 2014 with “Sincerely,
Constance J. Snyder”. There was no reply
while he stills receives mail from Dr. Bindra indicating he cares about his
accounts
Constance J. Snyder – Compliance
Officer
[INSERT
IMAGE OF DR. BINDRA]
Figure – Taken from Linkedin (2023)
Claims
In General with Brand New Day
Buster did not have claims sent to him that indicated he owed anything. It was assumed that any copay was billed up
front before his approved appointment.
Most everything, claim wise for 2023 went rather well with the exception
of Labcorp. They could not get in their
system the correct billing route. He has
one outstanding claim that they say sit on until we sort it out. He also has a Dermatology claim we were
working as an Imperial issue that turns out to be from 2022 and 2021 on BND’s
watch.
Rewards
What can you say any Reward is a
good thing? BND had a Reward
program. And due to Buster’s effort they
added a $10 annual reward for Health Risk Assessment (HRAs) that are filled out
by the consumer. Imperial has a
substantial Reward for the consumer executing fully an Annual Wellness Visit. Dr. Gandhi (PCP) mediated Buster’s AWV. As Buster’s and Dr. Gandhi’s parting were
coming to a close Dr. Gandhi comes into the exam room all excited because
Buster was due reward Money. Buster was
un-affected: Saying to himself: I have to see it first. It took some odd half
dozen phone calls and over five (5) months before the AWV monies were deposited
in Buster’s Nations Debit Card Account.
Gifts & Benefits
Unfortunately after working with
Nations for the better part of 2023, Imperial has decided to break the OTC contract. So many of his efforts to entrain Nations
will be lost starting 2024. This is a
good time to push for Imperial to add the grocery benefit. With a better grocery benefit Buster could
eat healthier like Quesadillas for the house..
Focus on Strengths
Buster discovered strengths based
assessment back in college. Exam and the
like by default evaluated for the students strength. In general they are objective measures of
competencies. Then he ran into
assessment and measures about deficits such as his Anxiety Disorder. Then around 2009 he runs into strengths assessment
centered about Behavioral Health. Now he
routinely evaluates both his strengths and deficits. Yet, one thing has become clear measurement,
assessment, and evaluation are likely. People
need to step up their self-reporting including determining Performance Earned
Values (PEVs), portable Assessment Values, Net Profile Efficiency, and Wellness
Profile.
Newsletter – Digital Presence
Buster used to publish MSG’s
routine Accountability MHSA Innovations Newsletter (AMIN). He know quite a bit about good and great
Newsletters. One thing he has developed
is using real people in Newsletters. The
OCHCA publishes online a monthly newsletter: What’s Up!. What’s Up! Always features real people.
Newsletter Quality / Value
SE = Star Equivalent
Last Reviewed: 20231129-W-Close year for CRC
UATR=Unable Able to Rate
Fear of being dropped
Buster being treated for a full
spectrum of Anxiety often feels being dropped for sharing his truth. Yet overall in the last ten (10) or so years
it would be hard to find evidence that his “Yellow Journalism” has harmed him
and his.
Lab & Pharmacy
We group lab and pharmacy
together because both are instrumental in keeping his primary medication,
Clozapine, steaming. Buster’s 28-day
Clozapine cycle begins with the doctor prescribing both a CBC (labwork) and the
prescription itself, the clinics communicates with the pharmacy of Buster’s
choosing: Gilbert Drugs. Gilbert reviews
the CBC results for any signs of Agranulocytopenia (actually neutropenia). If the lab is in the proper timeframe (28-day
cycle) and there is no sign of neutropenia (can be life threatening) then
Buster’s pharmacy delivers his monthly supply to Buster’s door. Since 2012 when Buster began retaining
Gilbert Drug’s their service has been stellar.
Buster and his 5.0 Star Pharm Guy, “Nick”, have been able to keep
delivering on Buster’s Clozapine with a single gap :0)
Select Records
Referrals & Approvals
Basically the whole process of
referral and approval has been driven by Buster. The retained BND Helpers were of no
help. When Buster asks for help there is
a potential crisis emerging. When he
asked the CCCHC retained BND helpers for help they did not deliver. He knew he needed his Ophthalmologist,
Dermatologist and Dentist. And in early 2023 he finds himself back to square
one updating the PCP on situational awareness. After the necessary referrals he
had to push forward the approvals. As of
November and dozens of phone calls he is ready to entertain that his services
and supports for 2024 are in place. Remember though he still has a claim with
Labcorp outstanding and he is facing the change in Imperial Rewards / OTC
contractor. In sum as has been he is
more his care coordinator than his Imperial
Care Coordination
Going back the Health Related
Engagement Concept (HRE-C) the majority of coordination was performed by Buster
and his Team MSG. For this term Team MSG
was: Avey C Asus, Magnus EMe, Lled Buzzard (Developmental Disabled – A Bit Slow),
KGT-A, LIV Vivo, Lys AAG and Sarah.
ADLs
Considers some Innovative Thinking
(STS LXE 20-Item)
ADL – Mainstream Assessment
GSM = Granular Scoring Methods
Buster Scores Buster – Self-Assessment
How is it Lived Experience?
Daily Activities that Promote Health
Part 1 of 2 – Heavy Hitting Items
Buster scores Buster
ADLs Derived Based on Lived Experience
Daily Activities that Promote
Part 2 of 2 – Mainstream Items
Buster Scores Buster
DORMIR – Sleep Science – The Big
Sleep
People of Interest – Christmas Report Card
Remembering Those That Killed Themselves (KIA)
KIAs with no Mention of MIAs
Mortality Entertaining a Degree of Urgency
Death Report
Certification of Vital Record (Pending)
Things for Older Adults
Buster’s Retirement Date =
December 22, 2023 (F)
Theme – Satisfaction as an Older Adult
Apply CEGU Probation to OAs
Concentration - DOMs = Dying Old Men
Sampling of Methods
Resistance to Dying Old Man Syndrome (DOM-S)
Prior studies and shares with
Brand New Day
Web Related – Online Accounts
Back in 2009 Buster signed on
with the OCHCA as a Technology Advisor.
To get up to speed he investigated was the Los Angeles Department of
Mental Health (LADMH). He even talked on
the telephone with the Director at the time
He gained insight into but not limited to: Electronic Health Record
(Hardware and Software), the RFP process, Personal Health Records, Patient
Portals, Personal computing for consumers and family members, budgeting, etc
(Kathleen Murray). We want to focus on
on-line accounts and patient portals.
Every time providers such as Imperial make changes on web-based content
as a new lab we have to go through the process of creating a new account. Now that we have a new Rewards intermediary
we have to get another portal. We have
somewhere around a dozen health portal accounts.
CMS Perspective
Since 2012 we have been working
on and off with CMS Medicare. CMS is the
entity that Medicare the Star Score System (SSS). It is very complicated and can actually
exhaust a contractor. Oodles of people
work delivering their concise Stars Report to their charges the Medicare
approved Health Plan Insurers of America (HPIA). Now is a good time to address disability even
though Buster will turn 65 in 2023. He kept trying to get up and work full-time
or as a small business owner. And then
bam a bout of Anxiety would fall and into the hospital we go. In one “Episode” they semi-committed to a 2
year stay in semi-lockdown while his life on the outside including his most
significant other ever (MSOE) was decaying. But is he not giving up on himself
he has a project in the works to remedy Housing issues with the OCHCA and
another to pitch to Yakult. Yakult
saying: We are “the world’s leading probiotic beverage created in Japan in
1935”… By chance they have a local in Orange County. And that’s all she wrote (Avey, 2023)
CalMHSA [STAYED – LAW1]
Further Studies Centered about
Imperial Health Plan
Approach = Prevention and Early
Intervention
Stigma & Discrimination Reduction
Student Mental Health
Suicide Prevention
Cast of Characters
Orange County Ophthalmology (Dr.
Taban)
While sitting in the exam chair
Buster observed a list next to the telephone that included most all of Taban’s Ophthalmology
staff. We feel that other than having
functional value it is an indicator of transparency and being Proud of Their
People. The Orange County Health Care
Agency also highlights their people in their monthly What’s Up Newsletter. With disclosures on pare with OCO and OCHCA
like this we here at MSG know who and how to complement and praise our Health
Care Workers (HCWs). We find that active
and passive anonymity “suck”.
Example of Transparency at
Ophthalmology Office Circa
CRC = Christmas Report Card
“Get on with who you are (PBG-2023)”
Let it fly > Animal Magic
Elemental & Resource Breakdown
A Resource Leveling Approach
Back in 2014 Buster became aware
of the Professional Quality of Life or PROQOL.
In no time he began to apply it to him and his. With the PROQOL results on his Primary Care
Physician, Chester D Mojica, he predicted that Dr. Mojica was in Professional
Burnout Mode (PBM). He also asked one of
his Primary Natural Supports (PNSs) if she was Burned Out. She replied “No”. And now some ten years later it would appear
that she was right. Yet, still Buster
determines he needs to level his resources and not become too dependent on a
single person, group, thing, etc.
Dependency Status
Buster Rates Buster
Yields a Dependency Indicative
Score
High score could be problematic
Last Reviewed: 20231219-TU
Honorable Mention
DSM Method Failed – Still too
many Behavioral Health Consumers underserved and inappropriately served
(Steinberg Programming Language – MHSA).
Salvo BB45 > Mark Refowitz
Converge Principle
INN_AMIN_0002_Convergence-Prinicple_14100905
Cast Of Characters
Sharing (Excerpts and Briefs)
Comparing
Professionals, Administrators,
and Leaders
May have extra Credential
In and Out of Network
Last Reviewed: 20231222-F
Q*M = Quick Star Method
Helpers
Non-MD helpers go by many names: Nurse, Therapist, Care
Coordinator, Brokers, Landlords, Committee Members, Treatment Planner, Life
Coach…
Focus about defunct local program and insurer Brand New Day
In non-profits the Best Help move up or onward
For Gary Zager (Cypress College & Janet Randall (CSUF)
SCR_BND_14091007_List-Log ALI V2023
(?) – Not available online
Specialists – Primarily In Network
MD and Medical Doctor Related Resources
Share with Dr. Richard Hoang – D.D.S., UCLA :0)
Q*M = Quick Stars Method score
December 14, 2023 RT and Retro
Cast of Characters Lister Lista
(*) Out of Network - Control
Psychiatrist
(**) Out of Network - Solution
for crumby coverage with Liberty Dental under Liberty
20231221-W-Sikh & Ravinder P Glitch
For Spiritual Support
Plan to return for a cup of
coffee
Rate Your Series
Cast by Modality or Procedure
Date of Encounter: 20181010-W @ 130 per Jocelyn
A Resource Leveling Approach
Last Reviewed: 20231222-F
Lesson Learned
Be patient while things develop
with Michelle Smith, JMB, JET, ASK, QLK, Steph, Etc. We have maintained a high degree of level one
Binary Scoring. In general, higher
scores are favorable.
Images @ the End -
None
Ethical
In Memory
Tuesday, July 19, 2022
Medication problems with Brand New Day by Keith Torkelson MS – CloZAPine Maintenance
Feature Image
Drug Plan pays nothing
towards consumer’s monthly CloZAPine
Simple Solution – Resume
Medication Delivery Every 28 Days
Briefer than the Brief
The “Insurance” needs to tell the
pharmacy, Gilbert Drug, that they are re-approved to deliver the “Consumer’s”
Medically Necessary medication CloZAPine which is the generic for
Clozaril. This medication was approved
for delivery every twenty-eight (28) days.
The “Insurance” had it right for over nine (9) years. In 2022 the pharmacy indicated that the
“Insurance” is interfering.
Second Feature Image
Brand New Day Desolation
Before
the COVID sickness we had a friend that relied on Brand New Day BND) and its
clubhouse to keep on top of his systems.
In 2020 BND pretty much dropped their clubhouse and member in-person supports. Our friend would be considered
young. Without the program helping him
with self care and support he gradually deteriorated. About one month ago he lost the bed that
served him well for quite a few years.
He is in poor condition and needs that help that BND used to be known
for. For now we will identify him as
NRP.
Brand New Day’s form asks for
these items in this order
“Please tell us about your
complaint”
BND Complaint Criteria –
Additional Information
Complaint Selections – Appendices
[Link to this full report]
Brand New Day HMO
https://brandnewdayhmo.blogspot.com/2022/07/medication-problems-with-brand-new-day.html
About the Complaint - Narrative Text
20220616-TH @ 945am
New and Improved Medication GAP(s)
Basically the consumer Keith “Buster” Torkelson’s health insurance changed a routine that has been working and effective since 2012. The change has created and will continue to create GAPs in his most important medication CloZAPine (generic for Clozaril). We request that you connect with the offending party to go back to letting the pharmacy fill and deliver his CloZAPine every 28 - Days. Ever since 2012 the Consumer along with his medication partners have for the most part achieved good orderly progress with his CloZAPine (generic for Clozaril) Management. In this paper we demonstrate the nature of said GAPs.
Bright Health Complication
(Vindicated)
Keith the Consumer is served by
Brand New Day (BND) as his health insurance provider. Recently it would appear his account with BND
was sold to another agency doing business as Bright Health. On the cusp of May-June 2022 Keith faced his
first insurance generated CloZAPine GAP. The first GAP lasted for three nights.
During this time he relied on his CloZAPine “For” Emergency Purposes
Only (FEPO).
Routine 28-day CloZAPine Maintenance Cycle (28DCMC)
In this study the consumer is
Keith “Buster” Torkelson MS. On the cusp
of May-June 2022 the pharmacy, Gilbert Drugs, was told by “the insurance” to
hold with filling of the consumer’s CloZAPine for a few days. It is within Keith’s power to reduce his
nightly CloZAPine down from 200mgs per night to 175mgs. Some say it is better to have something each
night rather than nothing. Slight
reduction for a few days per month will permit him to maintain continuity while
we work things out. For the purposes of
this paper “We” are Mentalation Solutions Group or MSG. In keeping with our tried and tested routine
that we call the 28-day CloZAPine Maintenance
Cycle (28DCMC) Buster’s psychiatrist prescribes 30-days’ worth each
time. Buster’s psychiatrist has been
adhering to his regimen ever since Buster linked with him back in 2018. With the 28DCMC Buster had enough to cover all
months including those 31 days.
Brand New Day Not Demonstrating Resilience Since COVID – GAP is Sustained
His insurance again indicates to
the pharmacy that they will withhold his CloZAPine at the cusp of
June-July. We have no information in
writing of who is accountable for disassembling the 28DCMC. Keith will again face a GAP in his essential and medically necessary nightly before bed
medication: CloZAPine generic for Clozaril.
We would normally submit an appeal to BND yet we already have two
outstanding concerns (complaints) with them.
Much of business as usual before the COVID Sickness has not been
revived. One complaint addresses an outstanding Reward that BND promised for
his Annual Wellness Visit (AWV). If BND is not going to keep their promises
they should inform their consumers in writing. The other broken promise is that
BND’s Healthy Food Benefit has not been
deposited since January of 2022. We hope
to have this issue resolved before the next GAP at the beginning of July 2022.
See what you can do – Thank you for your time and consideration. Avey C Asus for Keith “Buster” Torkelson MS.
20220604-SAT: Greetings,
Note to …Error Reporting…
We solicited for help the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). This part of what we said via MERPs website.
“We have a potential
medication error on hand that we would like you to be aware of. Keith Torkelson, MS is a consumer receiving
services from Brand New Day HMO. Rather
recently Keith’s account has been picked up by Bright Health Group. With Brand New Day since 2012: Keith has
never had a sustained medication GAP
with respect to his nightly medically necessary CloZAPine. We would like you to help return to the way
it was from 2012-2017 (Dr. Lee) and 2018-2021 (Dr. Bera). The way it was is that 30 days’ supply is
delivered roughly every 28 - days. Among
several reasons the 28-Day routine provided for a prudent reserve of this essential medication CloZAPine.”
Perfect Attendance Based on Time Tested Routines
Keith “Buster” Torkelson’s
doctors have agreed to sustain what we call the twenty-eight (28) day cycle
more formally the 28-Day CloZAPine
Maintenance Cycle (28DCMC). CloZAPine
requires monthly lab testing after the consumer graduates from the titration
stage to the maintenance stage. Lab work performed every 4 weeks or 28-Days permits
Keith to have his monthly blood draw on the same day of the week. This has worked out nicely for Buster as indicated by the fact that he has never
missed a scheduled blood draw (CBC) since 2012.
We coordinate by aligning the monthly blood draw with receiving Keith’s
monthly prescriptions of CloZAPine. Prescriptions
filled every 28-Days makes common sense. Keith DBA as Buster’s psychiatrist
writes the prescription for 30 day supply.
About the Complaint
20220719-TU: Complaint Brief – New and Improved Inappropriate
Service
This appeal or complaint regards the following with regards to Brand New
Day (BND). BND’s new and improved drug
plan is failing to serve. BND is failing
about the prescription CloZAPine. So far
since their improvement the plan refuses to serve the consumer
appropriately. In the process of serving inappropriately BND has generated a medication GAP. Next month at
the beginning of August 2022 we expect a two (2) day GAP in Keith’s CloZAPine. Before we submit this we are
going to call National Coordinating Council for Medication Error Reporting and
Prevention (NCC MERP to see where we stand from their angle.
BND Complaint Criteria – Share
times, people, and places
28-Day CloZAPine Maintenance
Cycle (28DCMC) – No Head’s Up!
We didn’t find out that we were
facing an insurance generated issue with the consumer’s routine medication
until May 31, 2022 (TU). Before this day
we received no correspondence from the insurer to expect any changes. Therefore we don’t know who within our
consumers insurance pushed through said change.
The change resulted in Medication GAP. We designate May 31, 2022
(TU) as the date this medication error began.
May 31, 2022 is the day that the consumer’s pharmacy said they could not deliver the CloZAPine as they had
since 2012.
Break in CloZAPine Pattern –
Interrupted (STR)
Issue Begins Roughly May 31, 2022
(TU)
BND Complaint Criteria – Share
times, people, and places
28-Day CloZAPine Maintenance
Cycle (28DCMC) – Pattern Senselessly Interrupted
Just before we send and or
publish this report (complaint) we are going to look online for anything about
prescribing CloZAPine in a good orderly fashion. At this point we have to assume the consumer’s
health insurer Brand New Day doesn’t understand the 28DCMC. Our study is driven by the fact that: Brand
New Day (BND) mediated the current
interruption with the consumer’s most important medication CloZAPine. This interruption generated a Medication GAP.
If not corrected there with be more GAPs
in the consumer’s Medication down the line.
The CloZAPine pattern of delivery (dispensing) every 28 Days has served
all involved well since the consumer signed on with BND in 2012.
Break in CloZAPine Pattern –
Interrupted (STR)
Research – Motive and Effort
MSGBase > Metadata
Even though we have entertained
the 28-Day Clozapine Maintenance Cycle (28DCMC) since 2007 the concept only
appears formally in our records on March 4, 2017. The motive for our efforts here is that we
have yet to find anything along the lines of the 28DCMC in research. We think we have something promising to
share. Whenever you look online about
information on CloZAPine you more often than not find something new. In addition the material is continuously
evolving. Here are two concepts we came
across with this episode of research.
Years ago Keith “Buster” Torkelson discussed the benefits of moving
CloZAPine related CBCs to every other month from every month. It is nice to find that others are interested
it the savings that fewer CBC would bring.
Can a 90 day supply of clozapine
be dispensed?
“In a recent international
consensus statement, recommendations were made to consider a reduced
hematologic monitoring frequency of every 3 months with the dispensing of a 90
day clozapine supply (if safe).” May 14, 2020
Can you dispense 30 days of
clozapine?
“Dispensing clozapine”
“If an RDA is rejected there will
be an option to request a Dispense Rationale through the website or contact
center. To obtain a Dispense Rationale, the pharmacist must have an ANC [Part
of a CBC] that was obtained in the last 30 days within the acceptable range.” Nov
15, 2021
In Practice Dispense Within 15-Days
The paragraph above most likely
applies to a different county. In
practice our pharmacy Gilbert Drugs prefers the CBC testing to be within
15-Days of dispensing our monthly CloZAPine.
Issue Began Roughly May 31, 2022 (TU)
(*) See Calendar Graphic Organizer
Concentrate about July 4, 2022 the GAP Day
Aside - Define Impinge
Impinge might be defined as having an effect or impact,
especially a negative one.
Brand New Day Criteria - Dates
and times (Part of Chronology)
Quantity 60 = 30 day supply
per month as prescribed by Dr. Rimal B Bera
Demonstrates 1-Day CloZAPine GAP (July 4, 2022)
Figure – Marked Up Calendar - Calendar GO
Brand New Day seems to be the
agency initiating the change with established and normative CloZAPine
coordination processes.
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Appendix
28-Day CloZAPine Maintenance
Cycle (28DCMC)
With held in favor of keeping
simple for the time being.
Further development needed before
we share the 28DCMC notion online.
Appendix
Coordination
These CloZAPine GAP issues are centered about the consumer’s insurer for
health care Brand New Day HMO - H0838.
Recently it appears that BND sold Buster’s account to Bright Health -
H4853. Yet, BND Member Services indicate
that BND still manages the Medicare accounts.
The consumer Keith “Buster” Torkelson is a Medicare account. Here we discuss a bit about coordination and
coordinated care in health care. Some of
the tools used in coordinated care are: Phone calls, letters, emails, treatment
planning, invoices, patient portals, electronic health records, Zoom virtual
meetings, and face-to-face meetings. As
time progressed since 2012 the consumer has been asked by BND to coordinate
more and more of their care.
Associated Items
Matrix - Appendix – Additional Information
Coordination in Context of the 28DCMC
Appendix - Additional Information
GAP Demonstration using Photographs
Below we include some photos that are in context for our request to resume the 28-Day CloZAPine Maintenance Cycle (28DCMC). The photos below demonstrate the new and emerging CloZAPine GAPs. We call pill bottle evidence. The prescribing doctor is Rimal B Bera MD. He has performed business as usual this year 2022. He will be brought into the discussion at the consumers next September 14, 2022 Medication Management Appointment (MMA). In reaction to the GAP we considered making an emergency appointment with Dr. Bera. Since 2012 the consumer has never had to make an emergency appointment with his Brand New Day associated Behavioral Health Doctor (BHD). Gilbert Drugs has been the consumer’s pharmacy since 2012. They eagerly wait for the return of the 28DCMC.
CloZAPine
dates Filled by Gilbert Drugs
CloZAPine 05/03/2022 & CloZAPine 06/03/2022 & CloZAPine 07/05/2022
Appendix - Additional Information - Coordination
[MERP HELD BACK]
Asking for Help – NCC MERP Method
NCC MERP
https://www.nccmerp.org/
The National Coordinating Council for Medication Error
Reporting and Prevention (NCC MERP)
Associated with:
08_Clozapine_Error_NCC_MERP_Route_22070501_Notes
Appendix
Brand New Day’s Methods
Over the years since 2012 we have
corresponded with Brand New Day (BND) regarding various Quality of Care (QOC)
issues. These included complaints,
grievances, and appeals. We have been
using some old BND related forms. Therefore,
we felt it would be a good time to update our BND form set. Member services indicated that the following
web address would provide what we were looking for in the name of forms.
BNDLink > “Filing a Complaint, Grievance or Appeal”
https://bndhmo.com/Members/Plan-Resources
Brand New Day Soliciting Feedback
BND aspects of “speaking up and
or asking for help”
FYI – Links to Brand New Day
Forms
Appeal Form
(English)
https://bndhmo.com/BrandNewDay/media/BND-Media/2021_Appeal-Form_EN.pdf
Grievance Form
(English)
https://bndhmo.com/BrandNewDay/media/BND-Media/2021_Grievances-Form_EN.pdf
Appendix
Itemizing Resources
Ever since signing on with Brand
New Day back in 2012 the consumer has jumped over many hurdles set by BND. In the process we have identified many
resources. Some are helpful and some are
not. We place BND itself right in the
middle. BND’s CMS Stars scores place
them above the middle at 3.5 CMS Stars out of 5.0 CMS Stars. The theme for this study (complaint) is a Medication Error that resulted and will sustain a Medication GAP. Again, without the “Insurance’s” intervention
the Medication GAP will be
sustained. In the table below we list
some of the consumer’s BND centered resources.
Other Routes - Theme – Medication
Error
Brand New Day Centered Resources
Some in-network and some out of
network
Appendix
20220706-W: Phone Notes – Medical
Board of California A Dead End
We now believe that Brand New
Day’s (BND) compliant and appeal processes are now for service year 2022
compromised. On behalf of Keith “Buster”
Torkelson (The Consumer) we have two outstanding complaints about 2022 with
BND. In the past we would get timely
responses. Not so is now the case! We looked into alternative methods before we
involve CMS Medicare. On July 6, 2022
(W) we called the Medical Board of California (MBC) to test out a resource new
to us. We told them that doctor had no
part with our BND issue for he is behaving the same as usual since the consumer
signed on with him back in 2018. The MBC
phone rep referred us to the CA Dept. of Managed Healthcare (DMHC).
20220706-W: DMHC Independent
Medical Review (IMR)
The contact information for the
DMHC given us is California Dept. of Managed Healthcare (DMHC) @ 888.466.2219. When we called the DMHC the call rotary said
there we 28 callers ahead of us. They
picked “Buster’s” call up at about the one hour point. Because they told us the initial number of
callers we could project ahead and do other tasks while we wait. We told them “I need help with a complaint”
and “A complaint that my health insurance fails to recognize”. They indicated that we might benefit with an IMG
or Independent Medical Review. We are
putting the IMG option on the back burner for a bit.
20220707-TH – Phone Notes –
Member Services Resource falls through
We decided that on behalf of the
consumer we were not using an up-to-date Brand New Day (BND) form or
method. Thus we opted to call BND Member
Services. We tried three different
dialing routes. First we used the dial
pad and put in BND # 1-866-225-4795.
This redirected us elsewhere to something not related to BND. Then we put in the number in our phone for
BND’s Isabel. The first time using
Isabel our call went through and we connected with “Rassy”. Rassy put us on hold for 12 minutes and 46
seconds. We said we have a “Medication
Issue” for our consumer. She said she
would email the form(s). The forms
didn’t arrive. Later we dialed a call
using the Google Route and their number comes up as that for Isabel. We are puzzled that the same number could
yield difference results.
FYI Brand New Day's Number as offered
by CMS Medicare = H0838
Brand New Day’s current CMS Stars Rating is 3.5 of 5.0.
Notes
20220708-F@11am – Phone Notes –
BND’s John is a good guy
On behalf of the consumer we have
tried to work with Brand New Day’s (BND) Member Service many times. In general Member Services is not very
helpful. This changed when we reached “John”. We have two outstanding complaints with Brand
New Day this service year 2022. We thought
that maybe the old form we were using didn’t contain the up-to-date mailing
information. We asked John about it and
he gave us a method to find both complaint and appeal forms. Marginally this is not an appeal. We asked John about interference by Bright
Health. He indicated that BND still serves
the Medicare clients.
20220708-F – Expiring Resources
We also asked John about two of
our corporate contacts Ali Khalkhali and Constance J “Connie” Snyder. He says Ali is in high administration and the
Constance may have retired. Maybe the
reason behind this problem is that the new hires or those appointed or promoted
really don’t know what they are doing.
In the end John said “Call back anytime”.
Figure - From Letter from Constance Snyder (CJS)
Losing those in the know
Professor Gary Zager’s Quote (2011)
“It is hard to get good help for the non-profits”
Appendix
- Share of Cost Aspect
About
the complaint – Who is the culprit?
We
can’t be certain who exactly altered the way Keith “Buster” Torkelson’s most
important medication is delivered. We
received no advanced notice by mail
or email indicating who is responsible. If we knew who was responsible they
might be more accountable. The GAP promoting change in “Buster’s” CloZApine
delivery cycle is something new yet not improved. Bright Health has been added to Brand New
Day’s letterhhead header. Again, we
called BND Member Services and the phone Rep indicated that BND is still
managing the Medicare accounts. “Buster”
is what is called Medi-Medi. For the most
part Bight is vindicated. Then we are
back to BND making a change after getting
it right for just over ten years.
The table below demonstrates that BND has no share of cost with the consumer’s CloZAPine. Overall CloZAPine is less than $1.00 per tablet. All of this is to not save anything across
six (6) or less tablets per month.
Associated Study
MSGBase >
From: 10_BMB_Clozapine_Gap_Intervention_22061101_Brief
Figure – CloZAPine Share of Cost
Breakdown
May 20, 2022 Statement as
provided by mail from Brand New Day.
BND’s Part D Drug Plan appears to
be challenged
Appendix
Share of Cost Table
The table below is just another
way to demonstrate that Brand New Day (BND) shares no cost with CloZAPine. The consumer “Buster” has come to rely on his
medically necessary medication CloZAPine.
For more than eight years and up and until this year 2022 the consumer
was prescribed a thirty day supply of CloZAPine delivered every twenty-eight
(28) days. Since the plan, BND, shares
no-share-of cost the decision to alter processes associated with CloZAPine more
likely not driven by BND’s financial concerns.
28 days V 30 days
2 night count = 4 MAX – Note Plan Pays Nothing towards CloZAPine which is the generic for Clozaril. Note: CloZAPine is not to be confused with any Benzodiazepine such as Clonazepam generic for Klonopin. We reviewed some medical records finding that in the records they use CloZAPine rather than Clozapine to reduce ambiguity.
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