Health Insurers Can Use IROs to Fairly Review Policy Cancellations

The article below from the LA Times provides an example of how health insurance carriers may increasingly be held liable for canceling health insurance policies for their members, based on "pre-existing conditions." In this case, the CEO of the company has rightly agreed to subject all future policy cancellations to external, independent review. In today's environment, health plans can ill-afford to be perceived as making self-serving policy cancellations, expecially in the middle of expensive treatment regimens. At the same time, when they are forced to provide benefit coverage for claimants that are clearly excluded according to plan language definitions, everyone ends up footing the bill.

In this type of situation, the only real way to determine what is fair is to review the medical evidence in the case. An Independent Review Organization (IRO) is set up to do just this kind of work. For health insurance payers, using an IRO for policy cancellation determinations represents an ounce of prevention that can be worth a ton of cure.

Health Net ordered to pay $9 million after canceling cancer patient's policy

By Lisa Girion, Los Angeles Times Staff Writer
February 23, 2008

One of California's largest for-profit insurers stopped a controversial practice of canceling sick policyholders Friday after a judge ordered Health Net Inc. to pay more than $9 million to a breast cancer patient it dropped in the middle of chemotherapy.

The ruling by a private arbitration judge was the first of its kind and the most powerful rebuke to the state's major insurers whose cancellation practices are under fire from the courts, state regulators and elected officials.

Read the rest of the article by clicking here:
http://www.latimes.com/business/la-fi-insure23feb23,1,5039339.story?page=1&ctrack=1&cset=true

Drug Errors & Over-Utilization - The Role of IROs

Drug errors inside hospitals and drug over-utilization are both critical issues that need to be dealt with in order to improve patient safety and reduce health care costs. The article below provides a snapshot of one aspect of this problem. As an IRO, we help hospitals, PBMs and health plans eliminate these problems, by providing independent medical reviews and hospital peer reviews that help them better manage drug delivery and costs. In the hospital environment, erroneous prescriptions can be reduced if practitioners know that their work is subject to regular outside review. For health insurance payers, drug utilization review is rapidly becoming a hot topic, since pharmacy benefits account for a large percentage of the increase in costs. IROs help bring accountability, transparency, objectivity and cost containment into the picture, which makes the system work better for everyone. --AGR

1 in 10 patients gets drug error
Study examines six community hospitals in Mass.
By Patricia Wen
Globe Staff
February 14, 2008
One in every 10 patients admitted to six Massachusetts community hospitals suffered serious and avoidable medication mistakes, according to a report being released today by two nonprofit groups that are urging all hospitals in the state to install a computerized prescription ordering system. Read the rest of the article at: http://www.boston.com/news/local/articles/2008/02/14/1_in_10_patients_gets_drug_error/

Applying Six Sigma to Hospital Peer Review

It's time to raise the discussion on how to apply six sigma quality principles to the medical peer review process in hospitals. While many "experts" are touting the value of apply lean six sigma methodologies to health care (see article below), nowhere is there more opportunity for improvement in hospital performance improvement and patient safety than in peer review. While some hospital groups have a repeatable peer review process that consistently and objectively measures practitioner performance, we talk to medical staff and peer review committee members every day who indicate the need for a holistic overhaul at their hospitals.

To achieve this, hospital leaders should start by studying six sigma principles and initiating a dialogue on how to apply them to their peer review committees. The application of these principles have positively impacted many industries, and which could be easily applied to peer review in order to raise performance, accountability and transparency. --AGR

Lean & Six Sigma: Fixing Healthcare a Process at a Time
By Carolyn Pexton

iSixSigma

With so many different issues facing the U.S. healthcare system the task of “fixing” it can seem insurmountable. Every healthcare executive knows the litany of challenges: rising costs, inadequate insurance coverage, capacity constraints, patient safety concerns, workforce shortages, increased competition, optimization of new technologies, etc. Some industry experts want a complete overhaul of the nation's healthcare system, while others tout information technology as a cure or consumer-directed healthcare as the inevitable wave of the future. Then again, for some people the problems appear so big that genuine, pragmatic and sustainable solutions are hard to envision.http://healthcare.isixsigma.com/library/content/c071121b.asp

NY Times Article on Spine Surgery

Back pain and its cure have resisted an easy answer since humans first stood up off all fours. Spine surgery is often less than successful, and the search for artificial discs, to replace discectomy (removal) and fusion has been recently a very hot topic.

The New York Times recently reveled that the so called science that got one such artificial disc FDA approved was severely compromised by conflict of interest issues, not to mention lousy science.

It turns out, per the report, that many of the physicians who inserted the discs and then reported on their benefit had, through a clever financial pass through, potential large gains if the discs were to be approved. Do you think their opinion of whether your pain had been relieved, whether the operation was a ‘success’, an improvement over other ways of doing the same thing, might be affected by the money they stood to gain if the FDA found the device effective, based on their own reports?

Furthermore, the statistical reporting of the effectiveness of the device somehow omitted 10 percent of the patients who got it. Would you guess those were the ones who really benefited? Or the opposite. Where did they go? Do you guess that omitting 10% of the initial sample had a numerical effect on how well the device worked?

Read the Article