At Health 2.0 Washington DC Conference, VP Business Development for Alere, Geoff Hyatt talked about collaboration and communication tools.
Above the Fold
Public Is More Savvy than Harris Polltakers
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?
Adam Bosworth on the Keas Challenge and the 3 things still missing in Health 2.0
We caught up with Adam Bosworth, CEO of Keas this week who had some new updates on the Keas API challenge including the open authoring environment and a new feature which will allow for more social engagement on the site. He also discusses Keas’ partnerships with pharma and employers and the three big gaps he still sees in the Health 2.0 ecosystem.
“I Like (Political) Science and I Want to Help People”
By 
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?
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
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
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.
The Yellow Stickie Ain’t Dead Yet
By HERBERT MATHEWSON
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
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.
