Newsmaker Q & A

Saturday, July 31, 2004

Stacey Brennan inherits Region C hot seat
New medical director ‘loves’ DME’s attention to the individual’s needs

COLUMBIA, S.C. - Stacey Brennan asked for it. The new medical director of the Region C DMERC had worked for a number of years as a medical director of an HMO at BlueCross BlueShield of South Carolina where most of the 350,000 beneficiaries were younger than 65. Now the nation’s newest DMERC medical director is shepherding claims in a region that hosts more than 11 million people aged 65 or older. To manage the millions of claims that will funnel through her group, Brennan will oversee a staff of 15-25 medical reviewers. She began work Feb. 23. Two months after she started, HME News talked to Brennan.

HME: Have you met with [former Medical Director Dr. Paul] Metzger since you took the job?

SB: No, he was gone for three months before I took the job, though I did shake his hand at an open door forum in March. I’m privileged to have a coordinator nurse who worked with him, and I have his notes, which are copious and very detailed and very helpful.

HME: What attracted you to the medical director’s job?

SB: I am in the same company. As an associate medical director, I [had hit a ceiling]. My responsibilities were not going to change.

HME: How much did you know about durable medical equipment?

SB:The state health plan is where I got to know it, and in an eccentric, maybe weird kind of way, love it. I like the attention to detail, and the fact that you really have to look at individual needs for the beneficiaries and their request for things.

HME: So this is an enormous increase in responsibility?

SB: It is, and that was an attraction to me - that I could have through my work an impact on policy that would affect a larger population. I was looking for an expansion of my role and responsibility. And I have wanted to work in a relationship with the government. That’s always been an interest of mine.

HME: When ever anything flares in DME, it’s usually in Region C. In terms of challenges, what do you see in Region C.

SB: I don’t think I as an individual can change what’s happening in terms of very high utilization, which is always changing. But I think I can contribute to internally helping us analyze our data and in a team approach look at what would be the most effective manner to not just study what this pattern is but to try to identify if this is truly fraud and abuse, and if so, how it can be stopped or remedied without at the same time causing pain or financial concerns to other suppliers who are not abusing the system.

HME: Many point to a lack of resources as the principal reason why the DMERC couldn’t get a handle on the Wheeler Dealer fraud. Now what?

The money problem is an issue. That’s not something I can get involved in. So much depends on the contract status and the awarding of it, but it really affects medical review, which is not my direct department (I’m in medical affairs) but I deal with the clinicians and the administrators in medical review daily. I know from the amount of documentation coming in with claims, based on our request, because of the need to do specific reviews, that it is overwhelming to us. We would like to have the money to hire another 10-12 nurses, but it’s not there.

HME: You’ve seen some of the changes put in place since the 10-point plan. Are you comfortable with the system set so that we don’t see another Wheeler Dealer fiasco?

SB: It’s working, but it’s very unwieldy. It’s creating terrible timeliness problems for everybody, including the suppliers. It’s a huge amount of paperwork. I would hope that with in the near future we are going to back off a little. That’s not our call. It’s CMS’s call.

HME: What are your responsibilities here?

SB: To be sure that our nurses or RTs, or heath professionals understand the policies, that they are not providing an interpretation that’s incorrect: in other words to keep things very consistent.
HME: How do you personally look at the definition of bed or chair confined?

SB: If anything is taking time, it’s my own personal thinking about that as well as discussing it with other medical directors and CMS.

HME: Does the doctor get to trump the medical reviewer?

SB: I dealt with that animosity a lot even on the provider side. Doctors know, deep down, that what is being reported to them as the reason their patient has been turned down for something is probably correct. And if they know there’s really something that doesn’t appear to be fair, it’s a communication problem. So if we can make the communication between physicians office and our reviewers both simplified and clarified to the point that there’s no confusion, that will help reduce some of the anger and resentment that physicians feel when they are notified that their patients have been turned down to receive whatever it is they have ordered. Physicians have been calling me from day one, and most of the time they have not gone out on the web to read the policy and #2, they really haven’t taken the time to talk to the supplier, who could do an excellent job of educating the physician

HME: So a lot of times, problems arise, simply, physician ignorance?

SB: I believe that. Here I was 17 years a family physician; I had several wheelchair patients. But I can’t recall ordering a wheelchair for someone, and then it was for someone who’d been in a power chair and needed a new one. I myself would have been an excellent case in point. If a new person had come to me for some sort of scooter or motorized wheelchair, I would not know where to look for policy

HME: Why is some info from a doctor given more weight than other info?

SB: It’s been that way. We need to build trust and feel that on our side we are getting a proper picture painted. So we have looked to the progress notes, but unfortunately it often falls short. All regions are are saying to CMS - that’s one of the things that Dr. Tunis’s committee is going to address. How can we have an understanding of a beneficiary’s need - one from the physician and one from the supplier.