New Irish Medical Assessments

http://www.examiner.ie/

IMC president Dr John Hillery said that while most doctors were willing to take part in the random assessments, it could not compel everyone to participate under current laws.

But, he said, the council believed it had waited too long for supportive legislation and had now decided to roll out its own competence assurance structures this summer.

The new assessment system will involve patients and medical and non-medical colleagues of the doctor filling in questionnaires, in confidence, about the doctor's performance, with a summary of the findings sent to both the doctor concerned and the council. As part of the investigation, lay and medical assessors will observe doctors at work.

Cosmetic Surgery Abroad: The Risks

http://home.businesswire.com/

People's decisions to go abroad for cosmetic surgery are largely based on economics, according to Lack, without enough regard to what's really important: quality and safety. Lack says people should consider these things before going under the knife:

The physician's ability might be an unknown: Patients in the U.S. have the benefit of knowing that physicians have to pass layers of accreditation, involving licensure, hospital privileging, board certification, regulated training and peer review. In other countries, you might not know the true qualifications of the person performing your surgery.

The facilities in which you get your surgery might not be regulated as those in the U.S., where there are three certifying bodies that accredit outpatient surgery centers and a fourth that accredits hospitals.

Board Certification & Health Plans

http://www.freep.com/apps

Board certification is a system through which U.S. doctors are tested regularly about key concepts in their fields of specialty. Certification for pediatricians once lasted a lifetime. That changed in 1987, when the American Board of Pediatrics required recertification every seven years.

Board certification is just one measurement of physician competence, said Don Nielsen, senior vice president for medical affairs for the American Hospital Association in Chicago. Many hospitals routinely monitor physician performance through peer-review committees and monthly meetings at which deaths and complications are reviewed.

"The time to ask is when you pick a health plan," Freed said in an interview Tuesday. If consumers pick plans that require board certification, they can be confident they will see a physician who meets minimum standards, Freed said.

AllMed Healthcare Management: Featured Independent Review Organization

http://msnbc.msn.com/

Medicine is complicated and sorting out the messes sometimes requires a mediator. That's where AllMed comes in.

For instance, the line between medically necessary and elective procedures blurs when insured patients expect to have everything covered, and when doctors are rewarded for performing more procedures. It's also difficult for hospitals to guarantee accurate and fair peer-review processes of their doctors.

The company employs 12 people, but taps a contracted network of more than 300 medical specialists from around the country to help review medical cases, either before procedures are performed or after. The contracted doctors make the call about whether a procedure is supported by medical facts in the case. The company's clients include insurance companies, health care providers, third-party administrators and claims managers. Whether an insurance company pays for such procedures has cost implications for everyone enrolled in a health plan, and for an insurer's bottom line.

Medical Disability Controversy In California

http://www.sacbee.com/

"I'm optimistic we can craft a solution through the regulatory process that will hold down rates and provide adequate benefits to workers entitled to them," Núñez said in a statement.

The administration, however, said no changes are planned until the Division of Workers' Compensation does its own analysis this summer.

"We need a big enough sample size so that we can really know what is happening," said Susan Gard, a division spokeswoman.

Under SB 899, a new methodology based on American Medical Association guidelines was imposed last year to determine permanent disability benefits. It also said the loss of future earnings would be considered in calculating awards. The goal was to give workers with less severe injuries lower benefits while those with a higher level of disability would get larger awards.

"Moral Turpitude" Issues With Irish Doctors

http://www.irishhealth.com/

However, he said any moral turpitude among doctors would be a cause for great concern.

Dr Hillery said new structures were needed at both medical school and hospital training level to identify those with problem behaviour, monitor them, offer them assistance and support if possible and where their behaviour does not change, prevent them from practising medicine.

He said current structures in medical schools and training programmes were not adequate to deal with problem students or trainees who may repeat this misbehaviour and potentially harm patients when they become fully-fledged doctors.

Dr Hillery said at present, medical students are dealt with under general disciplinary procedures applying to all students at colleges.

The Medical Digital Divide

http://www.boston.com/

Nationally, the state is in the vanguard of electronic medical record keeping -- not surprising given the high concentration of teaching hospitals and medical technology. But most of the computerization of records is being done by large physician organizations with more resources, creating a widening technology gap in the medical community.

Physicians who use computers can monitor patients' care more efficiently and reduce the possibility of medical errors. As a result, they consistently score better in quality surveys. Moreover, they earn 3 to 4 percent more money in ''pay-for-performance" contracts with health insurance companies.

But thousands of doctors like Young remain on the sidelines, mired in paper and in danger of falling further behind the field.

Computer systems for medical records cost $10,000 to $60,000 for each physician. They require training doctors and office staff, which can be disruptive, and extensive manual data entry to transfer records.

Medical Review In Kansas

http://www.kansas.com/

The insurance department receives about 1,300 health insurance-related complaints each year.

But there is no statistic on how many of those complaints challenge insurance company decisions that a treatment is experimental.

Steve O'Neil of the Kansas Insurance Department said only two situations lead to a state medical review: denial of a claim because a treatment is deemed experimental and denial of a claim because a treatment is deemed not medically necessary.

About 50 cases go to medical review each year. Patients win about half the time, O'Neil said.

He said he's not aware of a case in which the department has had two medical reviews on the same drugs for the same condition.

Dakhil, Bowles' oncologist, said that the small number of reviews indicates to him that physicians aren't taking cases that far.

With no way of knowing whether the state has already reviewed a treatment, doctors often will simply accede to the insurance company's denial and move on, he said.

"Physicians don't have the time to do a full literature review for every patient," he said.

Avastin & Independent Medical Review

http://www.sfgate.com/

Blue Shield officials say they are unaware of any clinical trials for Avastin and glioblastoma patients. Without solid evidence, such as peer-reviewed articles about the drug's efficacy and safety, they say they can't approve it.

Blue Shield's decision was supported by an independent medical review requested by the Almgren family.

A panel of three general oncologists, convened by the state Department of Managed Health Care, sided with the insurer in a 2-1 vote. The Almgrens object to the decision, primarily because neuro-oncologists, not general oncologists, treat brain cancer patients.

"We're not here to stand in the way of people to get safe and effective treatments. In this particular case, there is nothing that really supports this as a safe and effective treatment," said Dr. Eric Book, chief medical officer for Blue Shield of California, which is based in San Francisco.

California Doctor Pay Tied To Performance

http://msnbc.msn.com/id/11320227/

Program leaders say tying more of a physician's income to performance is needed to get them to take the incentives more seriously.

"If you look at what percentage motivates changes in behavior, we hear it's 5 to 10 percent," says Tom Williams, executive director of the Integrated Healthcare Association, an Oakland-based nonprofit that runs the ambitious program. "If you ask doctors to change their practices, the reward has to be worth it."

The health plans rate doctors in three areas: patient satisfaction, the adoption of technology and clinical behavior, such as the appropriate use of antibiotics.

The program, a 5-year-old initiative created by a broad consortium of doctor groups, health plans and employer associations, is the biggest of its kind in the country. It counts 225 physician groups as participants, including local heavyweights Palo Alto Medical Foundation, Hill Physicians Medical Group and Camino Medical Group, and affects 6.2 million patients.

Health IT Chronic Disease Management Online

http://www.spokesmanreview.com

Nationwide, chronic disease patients, including those with diabetes, make up only 20 percent of the Medicaid population, yet they consume nearly 80 percent of Medicaid's costs. In Washington state, this statistic is strikingly similar. In addition to high costs, the coordination of care is a major concern for chronic disease patients who often see multiple health care providers and have to manage several prescriptions.

The project, as proposed in the legislation, would give chronic disease patients and caregivers access to their own medical records and track their own health information through personal health records. The project will also give patients access to a single source of information on chronic disease and include several channels of communication with health educators. In return, physicians and caregivers will have access to complete, current treatment and health status information for chronic disease patients, using a Web-based virtual management tool.

An effective health IT chronic disease management program, such as this one, could result in a more than 3 percent reduction in overall Medicaid program costs while improving the access and quality of care.

The Skinny On Employer Sponsored Disability Insurance

http://www.fortwayne.com/

Thousands of other Americans have learned the hard way that employer-sponsored disability insurance – which covers illnesses and injuries sustained outside of work – can evaporate when it is most needed. It’s a little-known problem because the vast majority of the 50 million-plus workers covered by such plans never apply for long-term benefits.

A series of Supreme Court decisions has weakened the federal law that governs such voluntary company plans to the point where insurance companies now routinely deny claims, according to the handful of lawyers who litigate such cases.

Disability claims are treated as an administrative matter under the 1974 Employee Retirement Income Security Act. That means a policyholder who wins a dispute against an insurer can collect only the benefits he was supposed to get all along, and possibly some attorney fees, but no punitive or compensatory damages.

ERISA also makes disability cases hard to win. Insurers have the right to deny a claim if their own in-house doctors and nurses who review the medical information deem it baseless. That’s true even if the physicians who treat the policyholder make the opposite assessment, as in Brown’s case.

DMAA Announces Launch Of Project To Develop Standards

http://www.medicalnewstoday.com/

The Disease Management Association of America (DMAA) today announced the launch of an ambitious project to develop by year's end a uniform method for measuring and evaluating outcomes in disease and care management programs.

Underscoring the importance of this effort is agreement among the companies and individuals involved to support the final methodology and to put on hold independent standards development projects already underway. "Our members clearly understand the potential of this project to greatly expand acceptance of disease management by all payers, public and private," said Dr. Fetterolf, Corporate Vice President, Strategic Initiatives, for Matria Healthcare Inc.

Initial work on the project will involve a survey of the disease management community to collect data on how disease management organizations and others now measure outcomes. The steering committee established sound criteria for a survey instrument, using a process that examined questions of scope, statistical and actuarial considerations, collection methods and other issues.

Hospital Care Management Software: A Growing Marketplace

http://www.suntimes.com/

Yet apparently, it's still an unsaturated marketplace. Surges says that about 60 percent of the nation's 5,000 hospitals still have only manual means of helping a patient to exit, shop for a long-term care home, and get settled. And of the rest, half sorely need upgraded automation.

Hospital care management software is something of a genre-come-lately. Surges says only ECIN has automated both of the two functions posing huge workloads for hospital case managers: utilization management and discharge planning.

Utilization management is hospitalk for quality control monitoring and measurement against care standards, and capturing all the revenue a hospital is due. For example, an elderly patient undergoes surgery, and Medicare will pay for a seven-day stay but only if exhaustive paperwork (or ECIN tracking system) fully documents those seven days.

Discharge planning automation helps to vastly cut the time and anxiety of exiting and relocating to a convalescent home.