IN THIS ISSUE:
? Good News, Bad News for Physicians
? HMOs Held Liable for Physician Wrong Doing in Florida
? IOM Proposes Using Dummy Patients to Test Docs
? Rats! Imposing Quality Standards Doesn’t Pay Off
? HIPAA Privacy — More Bureaucracy Run Amok
? Fully Insured Consumer Driven Plans Available
? HRAs Most Likely Approach in Florida
Good News, Bad News for Physicians
Has medicine ever been under more pressure than it is today? Recent issues of “AMNews” capture the good, the bad, and the ugly facing the profession. On the good news side are recent court decisions that help physicians maintain their independence. Notable is the recent Supreme Court ruling in Kentucky Association of Health Plans v. Miller. The court not only unanimously upheld Kentucky’s any-willing-provider law, but “the reasoning behind the court’s decision is expected to reverberate far beyond the issue of any-willing-provider laws and resonate to any case involving managed care regulation,” according to an editorial in the May 5 edition. The article goes on to explain that “the greatest accomplishment in the Kentucky case was to address and eliminate the confusion” surrounding ERISA. It made a “clean break” from prior analyses governing the application of the ERISA preemption.
HMOs Held Liable for Physician Wrong Doing in Florida
In another case, Tanya Albert reports that the Florida Supreme Court ruled that “an HMO can be held accountable for the actions of a doctor it contracted with to take care of its members.” The plan may be held responsible even if the physician is an independent contractor who is following plan rules on medical necessity and records keeping, according to the article. The article quotes the Court’s opinion, saying, “While physicians of the past?may have constituted distinct independent entities?that model has been dramatically altered through the HMO concept?.”
IOM Proposes Using Dummy Patients to Test Docs
On the other hand, an article by Myrle Croasdale reports that the Institute of Medicine (IOM) is considering medical licensing and education reform. Perhaps you are perplexed that the federal IOM has anything to do with state licensing procedures, but that only shows how na?ve you are. When a bureaucracy decides to “do good,” things like jurisdiction and legal authority are mere obstacles to be swept away in the name of progress. Dr. Edward Hundert, president of Case Western Reserve University and co-chair of the IOM committee that issued the report, suggests “a corps of volunteer standardized patients making random visits to physicians offices,” to ensure the physicians are practicing medicine the way the IOM wants them to practice medicine – else lose their license. This should be just swell for the patient/physician relationship. Physicians will never know which of their patients is a spy for the IOM.
Rats! Imposing Quality Standards Doesn’t Pay Off
In the same issue Andis Robeznieks reports on a “Health Affairs” article that finds the premise of a recent study was flawed. Sheila Leatherman of UNC and Donald Berwick, MD of the Institute for Healthcare Improvement wanted to make a “business case” for quality improvement. That is, they wanted to show that investing in “quality” would pay-off financially for health plan sponsors. Alas, “the entity that makes the initial investment doesn’t reap the return on the investment,” according to Ms. Leatherman. Why? Because the people who receive the improved quality move on to other jobs or other health plans before the results kick in. The study involved case studies of the use of heparin, statins, diabetes management, smoking cessation, and workplace wellness. The study found, for instance, that the diabetes management programs “indicated short-term losses that could be overcome in 10 years. Because of enrollee turnover, however, researchers said it’s possible that neither organization will see much of a return on its investment.” What is missing from this picture is the patient. The study says that the health plan made the investment and the health plan didn’t see a return because the enrollees would be gone by the time the 10-year effect kicks in. I hate to be snide (no I don’t), but if it were the diabetic patient making the investment, the diabetic patient could reap the rewards, because this patient will still be diabetic ten years later.
HIPAA Privacy — More Bureaucracy Run Amok
HIPAA means so many things to so many people. It is the gift that keeps on giving. Today it is the privacy provisions, which according to reporter Joel Finkelstein, “allows physicians, health plans and other ‘covered entities’ to share health information, without obtaining patient consent, for treatment and payment purposes and for health care operations, such as quality assessment and underwriting.” The article says patients are already becoming wary of the information they give to their doctors. The article cites Michael Ostrolenk of the Medical Privacy Coalition as saying, “I don’t want bureaucrats from the Dept. of Health and Human Services looking at my records. The rule puts the Fourth Amendment on hold.” He says it gives public health and law enforcement officials “new rights to access patient records without consent,” according to the article. Lawsuits have been filed and legislative remedies have been proposed, especially to require consent by patients, but HHS “is focused on helping physicians and others implement the regulations,” says the article.
Fully Insured Consumer Driven Plans Available
Writing in “Employee Benefit News,” Jill Elswick says, “Complex state regulations, which require carriers to obtain approval before they may sell their products in the fully insured market, appear to have inhibited the growth of (consumer-driven plans for small employers).” The article quotes CareGain’s Amit Gupta as pointing out “there are eight million small to mid-sized employers out there, and they cover a total of 100 million people.” The article goes on to review the products available to small, fully-insured employers, including: Aetna’s HealthFund which is available in 38 states; HealthMarket which is available in seven states to small employers down to a group size of two; Destiny Health in Illinois and Wisconsin; and CareGain’s HealthcareIRA which can accompany other existing insurance coverages.
HRAs Most Likely Approach in Florida
Writing in the “Jacksonville Times-Union,” Sarah Skidmore warns that consumers may be confused by consumer driven plans. She says there are various models, “but the one most likely to make it into your benefits package is a Health Reimbursement Arrangement.” She says Aetna is offering these in Florida and the Florida Blue Cross Blue Shield plan will roll one out this summer. She adds that while the programs may seem confusing, insurers are “offering new tools and resources to help make these decisions because teaching members about their health care is a key component of the new products.” She cites a Xerox spokeswoman as reporting their 3,000 employees using an HRA are happy with the experience. The story also mentions that CAHI’s Merrill Matthews thinks employees may be tempted to spend all of their HRA money, resulting in higher costs, not lower. And Families USA’s Ron Pollack thinks the whole thing is “a bad idea.”
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