Category: Uncategorized

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

Aug 3, 2010• 13

By MICHAEL L. 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.

The New Rules for Insurance Appeals Under PPACA

Aug 3, 2010• 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.

The Yellow Stickie Ain’t Dead Yet

Aug 2, 2010• 4

By HERBERT MATHEWSON, MD

I’m sure that many of us “old timers” can remember the early days of computer implementation in our hospitals. At that time you couldn’t help but notice the dozens (or more) Yellow Stickies plastering the nurses’ station computers, usually around the monitor’s edges, filled with keywords, short cuts, new jargon, and other information helpful to them as they strived to give up their dependence on paper. Well, thirty years later, the Yellow Stickie ain’t gone just yet.

I had to go into my hospital last week to get an intravenous infusion to help me with the effects of a neuropathy. The receiving desk at the IV Infusion Center had three computer monitors with two people sitting at them. My physician’s orders were already printed out and were attached to my computer printout encounter form. After receiving my computer generated ID bracelet with bar code, I was lead into a room with four chairs, each one next to a computerized infusion pump with blinking lights and various sounds to convey different messages to the nurses caring for me. Each pump had touch-screen data entry and a multiple color display combined, was capable of at least three distinct alert sounds, and was neatly packaged to fit on a standard IV pole. The combination of four such poles, two automatic blood pressure machines with their display screens and alert sounds, the usual wall of oxygen, suction, electrical outlets, and signal lights, a R2D2-size mobile air conditioning unit standing in the middle of the floor with its coiled, white PVC exhaust duct winding to the wall, and four brand new baby blue Barca Loungers made me think that this is what a passenger cabin on a space ship would look like.Continue reading…

In the Public Interest

Aug 2, 2010• 10

By JOHN MOORE

The Health Information Exchange (HIE) market is the Wild West right now. Vendors are telling us that theyre seeing an unprecedented level of activity both for private and public HIEs. Private HIEs are being set-up by large and small healthcare organizations to more tightly align affiliated physicians to a hospital or IDN to drive referrals and longer term, better manage transitions in care in anticipation of payment reform. Public HIEs are those state driven initiatives that have blossomed with the $560M+ of federal funding via the HITECH Act.

But this mad rush is creating some problems.

While the private HIEs seem to have their act together in putting together their Request for Proposals (RFPs), such is not the case for the state-driven initiatives. Rather then formulating a long-term strategy for the HIE by performing a needs assessment for their state, setting priorities and laying out a phased, multi-year strategy to get there, far too many states are trying to “boil the ocean” with RFPs that list every imaginable capability that will all magically go live within a couple of years of contract reward. Now it is hard to say who is at fault for these RFPs, is it the state or the consultants they have contracted with that formulated these lofty, unreachable goals, but this is a very real problem and unfortunately, the feds are providing extremely little guidance to the states on best practices.

Facepalming Our Way into the Future

Aug 1, 2010• 11

By JOE FLOWER

The reform isn’t perfect, but maybe it’ll help us avoid disaster.

The rapidly ramifying crisis in health care may (we can pray) end all delusions. It may at least begin to weaken them by exposing them to the light, to the sobering effects of reality.

The reform act has not brought us to the Promised Land. By bringing us access without capacity, fierce restrictions coupled with vague language and loopholes, mandates coupled with fines low enough to become the cheap way out, strong new ideas that are only pilots, and tough commissions and task forces that have no teeth, the reform act delivers us into a period of maximum melee, in which the needs and desires of hospitals, doctors, citizens, politicians, insurers, drug companies, device manufacturers and hundreds to thousands of niche industries within the sector, get pitted nakedly against one another.

Everyone in this melee will increasingly be driven by the ratcheting drumbeat of cost, cost, cost—which is another word for over-use of resources.

It can seem at times like a kind of existential madness. But in fact we are engaged in a struggle over the very meaning and substance of who we are, what we do and why we do it. We can hope that at last and increasingly, we will be shedding our delusions and engaging in that struggle on the basis of some kind of reality.

Stupidity Everywhere

You know the facepalm moment. It’s that moment when you smack your hand on your forehead, accompanying the concussive thwap with the expletive of your choice, when confronted by a bit of numbskullery so dense as to tear the space-time continuum.

Interview with Aneesh Chopra

Jul 31, 2010

By Matthew Holt

At the Health 2.0 Washington DC Conference on June 7, 2010 we captured this interview with Aneesh Chopra, Federal Chief Technology Officer of the United States.

Not All Ratings Are Equal

Jul 30, 2010• 22

By JOHN MORROW

Earlier this month USNews and World Report released their annual list of America’s Best Hospitals. This list is terribly misleading and is a disservice to the readers of that magazine, in my opinion. The fine print is revealing:

“Central to understanding the rankings is that they were developed and the specialties chosen to help consumers determine which hospitals provide the best care for the most serious or complicated medical conditions and procedures—pancreatic cancer or replacement of a heart valve in an elderly patient with co- morbidities, for example. Medical centers that excel in relatively commonplace conditions and procedures, such as noninvasive breast cancer or uncomplicated knee replacement, are not the focus.”

Since when did breast cancer and knee replacements become so commonplace that they didn’t matter? On July 19, The New York Times published Doubt About Pathology Opinions for Early Breast Cancer, suggesting that diagnosing Stage 0 breast cancer was fairly difficult. And what is the bright-line test between “uncomplicated” and “complicated” knee surgery?Continue reading…

Use Emotion to Drive Adoption—Not Rejection—of Health IT

Jul 28, 2010• 9

By LYGEIA RICCIARDI

Last week I heard uber marketer Seth Godin speak about the power of fear. Fear is one of the strongest human emotions, based in the core of our brain–the “lizard brain” that evolved prior to our higher order thinking skills. Fear served us well throughout most of ancient history (stay away from the tiger!)–but it’s not always productive in modern day society.

Consumer fears about health information technology (health IT) privacy are a case in point. Surveys show that more than half of consumers voice fears which are, (in my opinion) appropriate, to an extent: risks such as discrimination are real, and public concerns should hold policymakers, vendors, and providers to the highest standard of privacy protection.

The real problem is fear mongering. Debroah Peel, founder of Patient Privacy Rights, has put herself and her organization on the map with sensationalism. As she said in a KTVU report earlier this month: “Anything that’s in there, any information that’s in there, can and will be used against you in the future. It’s very important to know that in the electronic health world…” and, “This is a nightmare. It’s nothing we’ve ever seen before in medicine.”

Extremist statements like this are usually misleading and often just plain wrong.. But a response that focuses on the logical and rational alone doesn’t cut it. In March Peel wrote an opinion for the Wall Street Journal online called “Our Medical Records Aren’t Secure.”

It got 179 comments. A measured rebuttal by Mary Grealy, President of the Healthcare Leadership Council, got only 4.Continue reading…

The Reform Dartboard: Predicting Healthcare Costs

Jul 28, 2010• 6

By Roger Collier

One thing about a democracy, everyone is entitled to publish their predictions about the future, and on the costs (or savings) of the Patient Protection and Affordable Care Act over the 2010-2019 decade, there are enough to cover the dartboard.

Whether any have hit the bull’s-eye is another question.

The two most authoritative darts so far are those of the CBO and CMS’ Office of the Actuary. Each assumes that reform will be implemented exactly as stated in the new law, with no successful legal challenges and with legislated cost reduction targets achieved. The CBO forecast is limited to federal spending, while the OA projections cover both federal and overall national expenditures.

The CBO’s well-publicized (by reform advocates, anyway) dart hit the board immediately prior to passage of PPACA with an estimate of federal savings of $86 billion (excluding advance premiums from the new CLASS long-term care insurance program), or slightly less than one percent of projected federal health care spending.

The OA dart, thrown a month later and applauded by reform opponents as contradicting the CBO forecast, landed on the $289 billion number for increased federal spending (prior to CLASS premium collections), and on $310 billion for increased national health care expenditures.

Interview with Esther Dyson

Jul 27, 2010

By Matthew Holt

SUBTEXT:After being a panelist at the Health 2.0 Goes to Washington Conference, Esther Dyson, Chairman of EDventure Holdings, gave a backstage interview. She talked about the three markets that influence Health 2.0; the market for healthcare, bad health, and health.