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Who Actually Is Reviewing All Those Preauthorization Requests?

Milton Packer thinks you should know how the system works

  • by Milton Packer MD

Several months ago, I was invited to give a presentation about heart failure to a group of physicians who meet every month for a lunch meeting.

Don’t worry. No company sponsored the talk, and I did not receive any payment. I accepted the invitation, because it seemed like to good thing to do.

However, the audience was a bit unusual for me. Among the 25 physicians in the room, nearly all were in their 70s and 80s. All were retired, and none were actively involved in patient care. I guess that explains why they had time in the middle of the day for an hour-long presentation.

I gave my talk, but there were no questions.

I had a few moments afterwards to speak to my audience. Since the physicians were not involved in patient care, I wondered why they wanted to hear a talk about new advances in heart failure.

The response surprised me: “We no longer care for patients, but we care about what’s going on. You see, most of us are employed by insurance companies to do preauthorization for drugs and medical procedures.”

My jaw dropped: “I just gave a talk about new drugs for heart failure. Are you responsible for preauthorizing their use for individual patients?” The answer was yes.

I was really curious now. “So did I say anything today that was helpful? I talked about many new treatments. Did I say anything that you might use to inform your preauthorization responsibilities?”

Their answer hit me hard. “Oh, we’ve heard about those drugs before. We’re asked to approve their use for patients all the time. But we don’t approve most of the requests. Nearly all of them are outside of the guidelines that we are given.”

I stammered. “I just showed you evidence that these new drugs and devices make a real positive difference in people’s lives. People who get them feel better and live longer.”

The physicians agreed. “Yes, you were very convincing. But the drugs are too expensive. So we typically reject requests, at least the first time. We figure that, if doctors are really serious, then they should be willing to make the request again and again.”

I was astonished. “If the drugs will help people, how can you say no?”

Then I got the answer I did not expect. “You see, if it weren’t for us, the system would go broke. Every time we say yes, healthcare becomes more expensive, and that isn’t a good thing. So when we say no, we are keeping the system in balance. Our job is to save our system of healthcare.”

I responded quickly. “But you are not saving our healthcare system. You are simply making money for the company that you work for. And patients aren’t getting the drugs that they need.”

One physician looked at me as if I were from a different planet. “You really don’t understand, do you? If we approve expensive drugs, then the system goes broke. Then no one gets healthcare.”

Before I had a chance to respond, he continued: “Plus, if I approve too many expensive drugs, I won’t get my bonus at the end of the month. So giving out too many approvals wouldn’t be a smart thing for me to do. Would it?”

I walked out of the room slowly. Although I had been invited to share my knowledge, it turned out that — this time — I was the real student.

The physicians in the audience taught me a valuable lesson. And amazingly, none of them showed a single slide.

Packer has recently consulted for Amgen, Boehringer Ingelhim, Cardiorentis and Sanofi. He was one of the two co-principal investigators for the PARADIGM-HF trial (sacubitril/valsartan) and currently chairs the Executive Committee for the EMPEROR trial program (empagliflozin).

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Senate’s final version of bill eliminates cap on municipal ambulance fees MMA opposed


Thank you for acting on the Ambulance Fee Alert we sent you on November 1st!


The sweeping health care cost containment bill approved by the Senate last week does NOT include the provisions opposed by the MMA to cap ambulance fees. Your calls on this important issue made a big difference.


As you recall, an early version of the Senate’s health care bill included provisions to cap municipal ambulance fees and impose a state-driven system to oversee the local fee-setting process. That proposal would have imposed financial burdens on cities and towns, and made it difficult for communities to fund emergency response services.


Fortunately, the Senate Ways and Means Committee eliminated the fee-capping provisions from the legislation that was debated and passed by the Senate. This came after productive conversations between the MMA, legislators, Senate staff, Fire Chiefs and other EMS Coalition partners, as we explained why ambulance fee caps would hurt local budgets and undermine high-quality municipal EMS programs. The MMA’s effectiveness on this issue was possible because of the large volume of calls that Senators received from local officials, as you responded to our Nov. 1 Action Alert. Your calls were the key to our success.


The health care legislation now moves to the House, where a bill is expected to emerge for debate early next year. When you see your Senators over the upcoming holiday season, please thank them for protecting local fee-setting authority for ambulance fees, and when you see your Representatives, please explain why ambulance fee caps would be bad for cities and towns. And please thank them all for supporting municipal issues throughout the year.


If you have any questions regarding ambulance fee legislation or the Senate health care bill, please call or email MMA Legislative Director John Robertson at (617) 426-7272 x122 at any time.


Thank You Very Much!

BoS on 11/21/17

Here is an updated agenda and the back up materials.  These back up materials contain the Schedule A financial summary the Town of Medfield files annually with the Massachusetts Department of Revenue, that gives a complete summary of the town finances.

20171121-Meeting Materials

MEETING I PPSTED TOWN CLERK·. TOWN OF MEDFIELD t{LCl::.ivtu · l'UWN OF MEDFIELD. MASS NOTICE POSTED IN AccoRDANcE wITH THE PRovisioNs oF M.G.L. cHAPrE28n9r~H,U~3~ WMENDED. Board of Selectmen OFFICE OF THf TOWN 8LERK Board or Committee PLACE OF MEETING DAY, DATE, AND TIME Town House, Chenery Meeting Room, 2"d Floor Tuesday, November 21, 2017 7:00PM Agenda (Subject to Change) 7:00 Call to Order Disclosure of Video Recording Announcement We want to take a moment of appreciation for our Troops serving in the Middle East and around the world. Appointments 7: 15 Medfield State Hospital Building and Grounds Committee Citizen Comment Action Items Selectmen are invited to the Eagle Scout Court of Honor on Saturday, December 2, 2017. Vote to sign the Eagle Scout Certificate of Achievement for: Garrett Theodore Gipson Roberta A. Raine Tyler James Hatch Stephen Daniel Williams Discussion of Board of Selectmen 2018 A TM Warrant Articles Pending Items Town Administrator Evaluation Discussion Town Wide Goals Veterans Service Officer Annual Appointments Lot 3 Discussion MSHMPC issuance ofRFP for Facilitation Services Licenses and Permits (Consent Agenda) Katie Walsh, owner of Capsule, requests a one day Liquor permit for the Holiday Stroll on December 1, 2017 from 5PM to 9PM. (70 North Street) MEMO requests a Parade Permit for the Annual Holiday Parade on Saturday, December 2, 2017 at 1 :OOPM. MEMO also invites the BOS to lead the parade and participate in the Tree Lighting Festivities on December 1, 2017 at Baxter Park. Town Administrator Update Update on 11/17 meeting with the DOT and Legislators regarding West Street/Route 109 Bridge Informational 2017 Schedule A Town House closed at lPM on Nov 22. Closed on 11/23 and 11124 for Thanksgiving Holiday. Cushman House Lottery Application for 67 North Street20171121-agenda-final_Page_2


Mixed grades for state budgeting

Truth and Integrit y in State Budgeti ng: What Is the Realit y? 60 Massac husetts Report Card Tra nspare ncy 2015 2016 2017 Category GRADE Consolidated Budget Website Provides Debt Tables Discloses Deferred Infrastructure Replacement Costs Discloses Tax Expenditures 3-year Avera ge 3-year tre nd — Reserve Funds 2015 2016 2017 Category GRADE Positive Reserve or General Fund Balance Reserve Funds Disbursement Policy Reserve Funds Replenishment Policy Reserves Tied to Revenue Volatility 3-year Avera ge 3-year tre nd — Legacy Costs 2015 2016 2017 Category GRADE Public Employee OPEB Funding Public Employee Pension Funding Public Employee Pension Funded Ratio* 62% 3-year Avera ge 3-year tre nd — Budget Ma neuvers 2015 2016 2017 Category GRADE Deferring Recurring Expenditures Revenue and Cost Shifting Funding Recurring Expenditures with Debt Using Asset Sales and Up-Front Revenues 3-year Avera ge 3-year tre nd — Budget Forecasti ng 2015 2016 2017 Category GRADE Consensus Revenue Forecasts Midyear Budget Adjustments Multiyear Expenditure Forecasts Multiyear Revenue Forecasts Revenue Growth Projections 3-year Avera ge 3-year tre nd Budget Forecasti ng evaluates whether and how states estimated long-term revenue and expenditure trends. Budget Ma neuvers evaluates whether states used one-time revenues, borrowings, asset sales, and other measures to achieve short-term budgetary balance. Legacy Costs evaluates whether states provided adequate funding, as defined by retirement system actuaries, for pensions and other promised retirement benefits for public workers. Reserve Funds evaluates states’ rainy day funds and other fiscal reserves, as well as any policies governing their use and replenishment. Tra nspare ncy evaluates the accessibility to the public of states’ budget practices. * Source Pew Charitable Trusts, 2015 Followed best practice Did not follow best practice key

Municipal Facilities Evaluation and Capital Plan

Meals tax revenue

meals tax

Medfield netted $135,123 for FY 16 (the last year for which we have the complete yearly figures) from our meals tax, which our annual town meeting (ATM) enacted a few years ago.  I think of the meals tax as the town’s chance to tax the residents of our surrounding towns for enjoying our excellent restaurants.   At the Tuesday meeting of the Board of Selectmen Mike Sullivan shared his historic record of our net since the ATM adopted the meals tax.  I especially like the trajectory and the rate of growth.  I also especially like seeing documentation that our restaurants are doing increasingly much more business year over year.

LOCAL MEALS TAX RECEIPTS FY15 - FY17 FISCAL YEAR SEPTEMBER DECEMBER MARCH JUNE TOTAL 15 16 17 $7,916 $33,405 $37,559 $30,743 $31,924 $36,886 $30,672 $29,462 $98,793 $36,886 $32,908 $135,123 $37,589

More on chip seal

I asked Maurice Goulet, the Director of the DPW, a follow up question about chip seal and got more really useful information back from him this morning (a copy of that email appears below – I also inserted Moe’s original information at the end).  The “capital” he references is the town’s annual capital budget, which typically allocates monies to resurface subdivision roads.

chip seal

On Sat, Jul 8, 2017 at 11:26 AM, Osler L. Peterson <> wrote:


I am sorry to be late in responding to your materials, but yes, that is hugely helpful, and exactly the quantification of the cost differential that assists me to understand the magnitude of savings.  I just had time to post your data on my blog, and I am betting that the residents will be equally as appreciative as I am at your putting that material together for us.

So a big thank you from me for doing that and for doing it so well and so clearly.

I guess I do have one follow up chip seal question as I think about it today, namely how many miles of chip seal do we typically do per year?  Even if the savings percentage is really high, if the actual total spending amount is not too great per year, we might still opt to asphalt – e.g. I bet the town residents might opt for pavement over chip seal if it only cost us $100K more per year.  Thanks in advance.



Osler L. Peterson, Esq.



It would be difficult to give you an estimate in roadway miles as our roadways differ so much in width, however speaking with Bobby Kennedy we average about $150,000 – $200,000 per year on chip seal.

With the calculations I had sent you, it would cost approximately $425,000 – $575,000 for overlay (does not include costs of adjusting castings and repairing driveway aprons) and $555,000 – $750,000 for mill and overlay if we were to resurface the same amount of roadways. This would drastically reduce the number of roadways we could maintain per year. Once our pavement management system is in place, we will have a better understanding of the town’s needs. Even with the pavement management system, it may not consider to utilize chip seal as much, reducing the number of roadways that are resurfaced. (Chapter 90 state funding allotment for Medfield is $395,076 per year plus usually $30,000 – $40,000 from capital) The roadways that are not resurfaced puts added pressure on the Highway Division for maintenance throughout the year.



From: Maurice Goulet []
Sent: Friday, July 7, 2017 8:30 AM
To: Osler L. Peterson <>
Cc: Mike Sullivan <>
Subject: Chip Seal and Overlay Comparison


Below is a comparison of Chip Sealing roadways vs. Pavement Overlay and/or Mill and Overlay as requested.

Consider a scenario of 1 mile of roadway that is 20 feet wide at current contractor prices:

5,280 feet long X 20 feet wide / 9 = 11,733 square yards

$24,639 – chip seal

$69,922 – pavement overlay

(65% savings)

(pavement overlay does not include raising structures such as catch basins, manholes and gates, and reconstructing driveway aprons affected by raising pavement elevation, pavement elevation changes also creates new drainage issues)

Overlaying on a distressed roadway develops reflective cracking through the new surface within a few years affecting longevity of the surface. Milling (grinding) and overlay would then be considered as the preferred method.

$24,639 – chip seal

$91,628 – mill and overlay

(73% savings)


Please let me know if you have any questions. Hope this is helpful.

Maurice G. Goulet

Director of Public Works

Medfield, Massachusetts