THCB

Categories

Month: August 2010

Should We Fear Genetic Testing?

• 16

By THOMAS GOETZ
Thomas Goetz

Though the prospect of learning about our DNA might seem wrapped in mystery and intrigue, genetic information is not so different from any other metrics we know about ourselves: Our age, our weight, our blood pressure. With a little scrutiny, any of these numbers can tell us something about our health and ourselves. It’s the same with a genetic scan – it gives us some perspective on our health, though far from the complete picture. It is, in other words, a place to start thinking about how we’re living our lives.

It’s important to remember, though, that genetics is a very new science, and that getting a scan today is the equivalent of buying the first generation iPod – it’s a work in progress, and will get much better as time goes on. There’s a lot that science doesn’t know yet about the exact influence of DNA on our health, and the journey is part of the ride. But it’s a rare opportunity, unprecedented, perhaps, in history, that the general public might be granted unfettered access to experience science as it happens. It’s not something that everyone will be comfortable with, but we shouldn’t underestimate how profound this opportunity is.Continue reading…

HIT Trends Summary for July 2010

• 5

By MICHAEL LAKE

Whirlsandtwirls This is a summary of the HIT Trends Report for June 2010. You can get the current issue here.

E-prescribing. Two surveys re-confirm that while e-prescribing adoption is rapidly increasing, utilization continues to lag, particularly with advanced features. HIMSS released a survey about industry support for a DEA rule of allowing for e-prescribing of controlled substances. In this study, 40% say their organizations use e-prescribing, but half of these report doing so in a limited way. The Center for Study of Health System Change confirms these numbers with their study reporting only half of e-scripts users send them electronically and only a quarter regularly use routing and formulary checking and interaction checking together. Barriers include alert fatigue and suspicions about the accuracy of formularies. There are a number of cross-stakeholder groups working on these utilization issues. They are critical.

EHR. Hospital outreach to affiliated practices is a model that makes a lot of sense now. This month HP announced a comprehensive services offering in this area that competes with similar services from its rival Dell. Services include marketing support to educate community physicians, financing mapped to expected incentives, packaged hardware and implementation services and a menu of solutions from its VAR and ISV channel. I believe that hospital-centric marketing may have also had a role in the acquisition of Picis by Ingenix. Picis automates ICUs, ORs and EDs in hospitals with gives Ingenix some acute care assets to combine with its CareTracker EMR. The ED solution could help with medication reconciliation. The rich clinical data sets are attractive targets for Ingenix analysis. And it’s a strong growth segment.

Continue reading…

Job Post: THCB Editorial

THCB is looking for talented interns to assist with editorial, research and web production tasks as our web site undergoes a major expansion. Perfect for a grad or med student with an interest in journalism, public policy, and/or the business of health care.  Work out of a great home office location in the Princeton area or remotely, convenient to both Princeton University and UMDNJ. Reasonable train ride from midtown Manhattan. Production and research opportunities may also be available in our San Francisco offices for qualified candidates.

Editorial candidates should have an in depth familiarity with at least one area of the healthcare or tech industries and strong writing and editing skills.  Web production candidates should know their way around content management systems like Typepad (our current platform) and WordPress, our CMS in the not-too-distant-future.  Basic photoshop / fireworks / gimp or comparable image editing software required.Continue reading…

Public Is More Savvy than Harris Polltakers

• 17

By JOHN C. GOODMAN, PhD

Are the nation’s polltakers part of a surreptitious plot to convince us that what’s good for us is bad and what’s bad is good? A new Harris poll is the third in the space of a week claiming that the public (or some subset of it) is badly misinformed about the Patient Protection and Affordable Care Act. This follows on the heels of similar polls commissioned by Kaiser and the National Council on Aging (which I have criticized at my blog).

Yet the people responding to these polls appear to have a much better understanding than those asking the questions. Consider this tidbit from Harris:

Eighty-two percent think the bill will result in rationing of health care or that it might (it won’t).

Really? Well, what would a reasonable person expect to happen if (a) 32 million newly insured people try to double their consumption of health care, (b) 70 million or so additional people are moved into much more generous insurance than they have today, (c) most of the remaining 200 million people are promised preventive services without the deductibles and copays they face today and (d) almost nothing is done to increase the supply of providers?

Do you think health services are going to magically emerge from thin air? Or is it more reasonable to anticipate significant rationing?

Continue reading…

“I Like (Political) Science and I Want to Help People”

• 11

By BOB WACHTER, MD

I thought I was an oddball in college. I’ve only recently learned that I was avant-garde.

Right before beginning college in 1975, I decided I wanted to be a doctor. Being the first-born son – with decent SATs – of an upwardly mobile Long Island Jewish family, I had relatively little choice in the matter. Notwithstanding this predestiny, I felt confident that medicine was a good fit for my interests and skills.

But on my med school interviews four years later, I stumbled when the time came to answer the ubiquitous, “Why do you want to be a doctor?” question. The correct (but hackneyed) response, of course, is “I like science and I want to help people.” You’ll be comforted to know that I had no problem with the helping people part. It was the science thing that threw me for a loop.

It wasn’t that I didn’t like science, mind you. I found biology interesting, and organic chem was kind of cool, in the same way that Scrabble is. But I barely tolerated Chem 101, and disliked physics.Continue reading…

Docs and Insurers Posture on Report Cards, But Is Silence the Real Goal?

• 13

By MICHAEL L. MILLENSON
 

Millenson  Report cards are back in the news.

The Washington Post (via Kaiser Health News) is warning about the difficulty of rating individual physicians. Meanwhile, spokesmen for the insurance industry and the doctor industry (a/k/a the American Medical Association) are content with huffing and puffing about the perfidy of any report card that’s about them.

 In late July, for instance, the AMA sent letters to more than 40 health insurance companies requesting they investigate the reliability of their physician rating programs in the wake of RAND studies casting doubt on how low-cost and high-cost doctors are classified and on some quality rankings. That work was partly funded by the AMA and the Massachusetts Medical Society, which is also suing the Massachusetts Group Insurance Commission (GIC) over its physician ranking effort.
 

I'd have more sympathy for the docs except for the fact that the GIC effort has actually been one of the most intensive in the country to take into account quality as well as cost. Moreover, GIC executive director Dolores Mitchell has been a fierce pro-consumer advocate, not a role typically filled by your local medical society. (One local profile called her a “change agent” who “doesn’t take any guff.) And despite the complaints, there has been very little effort by the AMA or most other medical societies to work with insurers to provide the kind of timely clinical data (as opposed to claims data) that would make report cards more useful to patients.  The search for the perfect is too often a deliberate tactic to delay the implementation of the good.

Continue reading…

The New Rules for Insurance Appeals Under PPACA

• 2

BY KATHERINE MATOS

On July 22, the Obama Administration released interim final rules that allow patient appeals of health insurance coverage decisions as required under the Patient Protection and Affordable Care Act (”PPACA”) and Health Care and Education Reconciliation Act (”Reconciliation Act”).  Published by the departments of Health and Human Services, Treasury, and Labor, these rules create standards for the internal and external processes by which patients can appeal adverse benefits decisions.

Prior to these rules, coverage appeals were governed by contract and State law.  Forty-four States have created some form of external appeal process for insurance coverage decisions; however, their coverage is limited and the processes vary greatly.  Effective January 1, 2003, changes to the Employee Retirement Income Security Act of 1976 (”ERISA”) regulations provided standards for internal appeals processes.  However, these standards only apply to employer-sponsored group health insurance.

As stated in the Obama Administration fact sheet entitled, “Appealing Health Plan Decisions,”

Today, if your health plan tells you it won’t cover a treatment your doctor recommends, or it refuses to pay the bill for your child’s last trip to the emergency room, you may not know where to turn. Most health plans have a process that lets you appeal the decision within the plan through an “internal appeal” — but depending on your State’s laws and your type of coverage, there’s no guarantee that the process will be swift and objective. Moreover, if you lose your internal appeal, you may not be able to ask for an “external appeal” to an independent reviewer.

Internal Appeals Process

Under the rules, new health plans beginning on or after Sept. 23, 2010, must have an internal appeals process for beneficiaries to challenge “adverse benefits decisions” — a “denial, reduction, or termination of, or a failure to provide or make a payment (in whole or in part) for a benefit.”  Such adverse benefits decisions may be based on individual eligibility, benefit coverage, limitations on otherwise covered benefits (such as preexisting condition exclusions, source-of-injury exclusions, and network exclusions), and a determination that a benefit is experimental or not medically necessary.

In addition, health plans must do the following:

  • Notify a claimant of a benefit determination as soon as possible;
  • Provide claimants, free of charge, with the evidence relied upon and the rationale for the decision;
  • Avoid conflicts of interest by making decisions regarding hiring, compensation, termination, and promotion independent of a claims adjustor or medical experts record of denial of benefits; and
  • Meet additional requirements for notice, including information on internal appeals and external review processes.

However, these requirements do not pertain to so-called “grandfathered health plans” — those health plans that were in existence before March 23, 2010 when PPACA was enacted.  In the individual market, health insurance providers must meet the foregoing requirements as well as the following three:

  • Applicants for individual insurance must be allowed to appeal initial eligibility determinations;
  • Internal review must be limited to a single level, allowing claimants to appeal to external or judicial review immediately; and
  • Insurers must maintain all claims and notices for a minimum of six years, which is already required of employer-sponsored health plans under ERISA.

External Appeals Process

If the internal appeal is denied, patients may choose to have the claim reviewed by an independent reviewer.   According to Appealing Health Plan Decisions, States are encouraged to adopt the National Association of Insurance Commissioners (NAIC) standards in “their external appeals laws to adopt these standards before July 1, 2011.”

The NAIC standards call for:

  • External review of plan decisions to deny coverage for care based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit.
  • Clear information for consumers about their right to both internal and external appeals — both in the standard plan materials, and at the time the company denies a claim.
  • Expedited access to external review in some cases — including emergency situations, or cases where their health plan did not follow the rules in the internal appeal.
  • Health plans must pay the cost of the external appeal under State law, and States may not require consumers to pay more than a nominal fee.
  • Review by an independent body assigned by the State. The State must also ensure that the reviewers meet certain standards, keep written records, and are not affected by conflicts of interest.
  • Emergency processes for urgent claims, and a process for experimental or investigational treatment.
  • Final decisions must be binding so, if the consumer wins, the health plan is expected to pay for the benefit that was previously denied.

If State laws don’t meet these standards, consumers in those States will be protected by comparable Federal external appeals standards.

As Kaiser Health News reported, “This is a regulation that benefits everyone — consumers get protections, business and providers get more certainty in the rules and the need for litigation to settle these issues should be dramatically minimized,” Phyllis Borzi, assistant secretary of the Department of Labor, said at a briefing for reporters Thursday.

Consumer Assistance Grants

However, procedural rights for consumers are not sufficient to ensure proper appeals.  “Not enough consumers know this is an option that they have,” said Angel Robinson, the consumer advocate in the Iowa Insurance Division, according to Kaiser Health News.

In addition to the new requirements for internal and external appeals processes under the interim final rules, the federal government is offering nearly $30 million in resources to States and Territories to strengthen and establish consumer assistance programs.  Specifically, these programs are charged with:

  • Helping consumers enroll in health coverage;
  • Helping consumers file complaints and appeals against health plans;
  • Educating consumers about their rights and empowering them to take action; and
  • Tracking consumer complaints to help identify problems and strengthen enforcement.

Katherine Matos is a 3rd year student at Seton Hall Law and a regular blogger at Health Reform Watch.com. [http://www.healthreformwatch.com/] She is the principle inventor on a patent application in the field of medical imaging, resulting from her research as a student at Stevens Institute of Technology. After graduating with degrees in biomedical engineering and history in 2008, she volunteered with the Irish government in the Health Services Executive. At Seton Hall Law, Katherine has researched federal oversight of nanotechnology with Professor Jordan Paradise and non-profit governance with Professor Melanie DiPietro. She worked as a summer associate at Fitzpatrick, Cella, Harper & Scinto in 2009 and at Robinson & Cole in 2010.

Interview with Trisha Torrey

• 1

By Bianca Grogan

At the Health 2.0 Goes to Washington Conference, June 7, 2010, Trisha Torrey who writes the Guide to Patient Empowerment for About.com, gave a backstage interview. She mentioned how excited she was to be at the conference to represent the patient’s point of view.