While the U.S. Spends Heavily on Health Care, a Study Faults the Quality

Usually paying a premium for services and goods means you’re getting a product of higher quality in return. For example, organic produce costs more than conventionally-grown produce and octane 92 gas costs more than octane 89 but you get what you pay for: better fruits and cleaner gasoline.

According to a study conducted by Commonwealth Fund, a nonprofit research group in New York, this get-what-you-pay-for formula is not the case for the American healthcare system. The report shows that the United States spends more than twice as much on each person for health care as most other industrialized countries but has fallen to last place among those countries in preventing deaths through use of timely and effective medical care.

In summary: Americans are paying way too much for very little. The study also examines costs and inefficiencies within the American healthcare system. The administrative costs of the medical insurance systems consume much more of the current healthcare dollar, about 7.5 percent, than in other countries.

One avenue that healthcare payors can take to reduce costs is to outsource review cases to independent review organizations (IRO). IROs are efficient, cost-effective and knowledgeable, providing peer specialists who are actively practicing and up-to-date with today’s medical standards. By ensuring that reviews are done according to current medical standards, IROs reduce extraneous administrative costs of rework and re-reviewing.

Read the full article.

Aggressive New Recommendation for Warding Off Heart Disease in Some Children

By now, most people in the medical profession are aware of the American Academy of Pediatric’s recommendation for wider cholesterol screening for children and more aggressive use of cholesterol-lowering drugs for kids, starting as early as age eight. The controversy of the recommendation stems from the fact that the AAP’s statement comes from mere speculation of how statins work in adults. According to an article in The New York Times, AAP’s doctors believe that statins will function the same in children as they do in adults, a speculation that is absent of any evidence-based medicine and clear data.

The importance of evidence-based medicine is clear in this controversial mishap. Just two days after issuing the recommendation, AAP retracted the statement, offering apologies for unclear thinking and lack of evidence-based medicine. Relying on evidence-based medicine is a sure-fire way to make the best decisions for a treatment. An independent review organization bases its decisions and recommendations on evidence-based medicine in order to determine medical necessity and increase patient safety.
Read the initial article about the American Academy of Pediatric’s recommendation

The Evidence Gap: Weight the Costs of a CT Scan's Looks Inside the Heart

The latest feature of The New York Times series, The Evidence Gap, delves into controversial issue of emerging and cutting edge technologies in healthcare. The article, “Weighing the Costs of a CT Scan’s Look Inside the heart,” offers the pros and cons of a new cardiology medical device. The CT Scan can provide cardiologists with a new way of looking into patients’ arteries, a boasting reputation of offering cutting edge technology as well as extra revenue. On the other hand, the new CT Scan exposes patients to large doses of radiation. It is costly machine—$1 million—and an expensive procedure that has yet to yield better results.

According to The New York Times, this new CT Scan controversy showcases the American healthcare system as: “faith in innovation, often driven by financial incentives [which] encourages American doctors and hospitals to adopt new technologies even without proof that they work better than older techniques.” The CT Scan is just one of many costly procedures that leads to hundreds of billions of superfluously spent dollars, with no justification.

An independent review organization (IRO) is helpful in a situation like this because they back their decisions with evidence-based medicine. Furthermore, they weigh the benefits of a procedure—detecting heart disease—against its risks—high radiation exposure levels. All in all, an IRO can decide whether its medically necessary for a patient to receive a particular treatment, elimating unnecessary procedures, reducing the nation’s superfluous spending on healthcare, while making sure patient safety is the top priority.

Read the full article

With a Tiny Bit of Cancer, Debate on How to Proceed

The New York Times reported that oncologists are able to catch more lymph node abnormalities than ever thanks to sophisticated and sensitive lymph node biopsies. What seems like a medical advantage—the ability to catch even the slightest hint of cancer—is actually causing more problems for oncologists who are unsure of what to do with the micrometastastic diagnoses they are making.

Currently no standards of care exist for the diagnosis of micrometastases—wisps of tumors too small to be considered full-fledged metastases. This means that oncologists are navigating through murky waters filled with an abundance of treatment decisions and options while worrying whether a treatment of these minute clusters of cancerous cells will benefit the patient in the long term.

Independent Review Organizations come into the equation here. With the combination of emerging standards of care and ever-advancing screenings, diagnoses and treatments, making the correct and informed decision to best benefit a patient is especially important, requiring demanding research and thorough knowledge. An IRO offers the knowledge of a specialist to help payers make the best decision for patient care.

Read the full article

5 percent of Mass. taxpayers uninsured, some fined

This article shows how Massachusetts is making progress in enforcing its new law regarding universal healthcare coverage for all of its residents. We're in favor of it. In order to lower costs and improve health care quality in this country, it's essential that we get everyone into the risk pool. Massachusetts is leading the way in this area, hopefully paving the way for a similar initiative at the national level once a new president is elected. As an independent review organization that is deeply involved in allocating health care resources in the US, we feel that a universal coverage mandate will help drive costs down and is a key step toward healthcare system transformation.

By STEVE LeBLANC, Associated Press Writer

BOSTON - Nearly 100,000 Massachusetts taxpayers have been fined for failing to obtain health insurance, even as a major survey concludes the effort to create near-universal coverage in the state is meeting key goals.

Five percent of taxpayers failed to obtain health coverage last year, and more than half of those — about 97,000 — were forced to forfeit their personal exemption — worth $219 — after it was determined they could have afforded health care.

Two percent of taxpayers — about 62,000 — were found not to earn enough for health care, avoiding fines. Under the landmark law, taxpayers must show they are insured or face penalties. The numbers were based on a review of 86 percent of expected tax filers for 2007.

The state's first-in-the-nation universal health insurance law required everyone in the state to be insured by July 2007, except for those who secured a waiver proving they couldn't afford insurance.

Read the whole article

Utilization Review & The Role of Independent Review Organizations

This article points to the critical role that utilization review plays in effective medical management, and the increased exposure that organizations face if they don't review the medical necessity of advanced patient treatments and hospital stays . With constantly changing care standards, the need to protect the integrity of patient care while limiting the impact of increasing costs, UR professionals play a pivotal role in today's health care delivery system.

UR organizations are only as good as the medical specialists who review their more advanced cases. For this reason, most medical management firms and UR organizations tap into the peer specialist capabilities of an independent review organization (IRO), which provides them with pre-authorization of their most complex and difficult claims. Since UR organizations can't afford to build/maintain a panel of these specialists, IROs represent a cost effective alternative which allows them to ensure that all complex claims determinations are made by board certified specialists who are in active practice. We provide these services to hundreds of UR and case management professionals in leading health care payor organizations across the US.

May 12, 2008

Strong Utilization Review Committees Can Prevent Inappropriate Hospital Admissions

Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues.

By Nina Youngtrom, Managing Editor, (nyoungstrom@aispub.com)

With all the pressure they face to reduce medically unnecessary admissions, hospitals need strong utilization review (UR) committees — especially since there have been few consequences for physicians whose admission decisions conflict with strict Medicare regulation and guidance (though that is starting to change).

An effective UR process, powered by highly trained case managers and physician advisers, is a great way to help prevent inappropriate inpatient admissions, according to Atlanta attorney Mitch Mitchelson, who represented the first hospital to settle a false claims lawsuit for alleged medically unnecessary inpatient admissions, and physician Robert Corrato, M.D., CEO of Executive Health Resources in Newtown Square, Pa., who served as a medical-necessity expert in the case.

Increased Scrutiny on Admission Necessity

Admission necessity has probably never faced more oversight - from recovery audit contractors, Medicare quality improvement organizations and program safeguard contractors (which are morphing into zone program integrity contractors). With advances in medicine and technology, more procedures can be performed on an outpatient basis, putting pressure on hospitals to establish inpatient medical necessity.

Read Entire Article

New Drug Treatments Drive Increased Utilization Review

This article highlights an initiative to create an evidence-based approach to evaluating the myriad of new medical devices and drugs that are hitting the market, and which are difficult for health care payers to track and evaluate for coverage. This makes good sense. With the exponential growth in new drug therapies, it's getting harder for payers to stay on top of what should be covered and what should not at the macro level. This is particularly important in light of the cost of many new drug regimens, and the need to control over-utilization. At the micro level, it means that more payers (including PBMs) are seeking outside help from IROs in order to make medically necessity determinations, develop drug formularies, and to handle member appeals when specific drugs or devices are denied.

FDA news Drug Daily Bulletin April 14, 2008 | Vol. 5 No. 73

Comparative-Effectiveness Bill to Hit Senate

A bill establishing a comparative-effectiveness research institute is scheduled for introduction in the Senate this week, congressional staffers say.

The Comparative Effectiveness Research Act of 2008, sponsored by Sens. Kent Conrad (D-N.D.) and Max Baucus (D-Mont.), would establish an institute to evaluate the effectiveness of different drugs and medical devices that exist for the same treatment.

The creation of such an organization was the subject of a public meeting held last week by the Medicare Payment Advisory Commission (MedPAC), an independent agency that advises Congress on issues affecting Medicare. The group supports a comparative-effectiveness program and recommends that Congress establish an independent entity to sponsor and disseminate such information. The entity would conduct prospective, head-to-head clinical trials of competing products as well as clinical reviews.

Read The Full Article

Medication Mismanagement On The Rise

This article points to one of the growing impacts of the cost and complexity of drug treatments, another indicator of how U.S. health care is in serious need of a makeover. The complexity of drug offerings is staggering, with hundreds of new pharmaceuticals hitting the market each year, and hundreds more in the pipeline. In addition, the cost of these treatments is directly driving double digit increases in health care costs. Pharmacy Benefit Management companies (PBMs) and drug utilization review firms are growing at a rapid pace, trying to manage the allocation of benefits and help health insurance payers to reduce the increases in costs. As the complexity of drug interactions skyrockets, Independent review organizations (IROs) are playing an increasing role in reviewing the medical necessity of drug utilization, by using specialists to provide medical peer review of drug benefits.

More prescriptions, greater confusion

Medications improve the lives of seniors, but errors in taking them can be lethal

Excerpts from an article by Tanika White, The Baltimore Sun

March 9, 2008

"Medication mismanagement among seniors is a growing problem in the United States. Some experts estimate that half of all seniors mismanage one or more of their medications, and seniors are twice as likely to end up in emergency rooms because of drug safety issues.

As the baby boom generation ages - and older Americans take more medications to deal with chronic illnesses - medical professionals have become increasingly concerned about the issue.

"Not only is it getting worse, it has become one of the major sources of hospitalizations in the country and one of the greatest preventable causes of illnesses - and costs associated with illnesses - in this country," said George Lowe, director of medical services at the Overlea Physicians medical clinic in Northeast Baltimore. About 60 percent of his patients are seniors."

Read the entire article: http://www.baltimoresun.com/news/health/bal-te.md.meds09mar09,0,85144.story

Accountability + Transparency = Improved Quality + Patient Safety

Building & Leading a Continuous Improvement Culture

As I roam the internet looking for new knowledge and ideas on how to improve External Peer Review,I'm amazed at the plethora of statistics, data, measures and analysis that's being done in the name of improving hospital quality and patient safety. My hat goes off to those who use analytical tools as the foundation for performance improvement in hosptials.

Having said that, in my humble opinion, we could make much great strides in much shorter time if management and medical staff focused more of its effort on building accountability and transparency into their hospital cultures, as opposed to spending more time and money crunching numbers.

An increased emphasis on setting clearer practitioner expectations, measuring and monitoring their performance, sharing performance data and holding poor performers accountable is what's in order. We see/hear of too many situations in hospitals across the country where conflict of interest, conflict avoidance, cover-ups and other behavioral dysfunction allow under-performing physicians to keep doing what they are doing.

What I'm advocating is medical staff leadership that goes beyond analysis and statistics, but rather uses this data to place increased emphasis on creating a culture of continuous improvement. In such a culture, sentinel event data is openly shared, performance is actively measured, practitioner work is subjected to regular/period external peer review, and poor performers are put on a corrective action program, no matter who/how important they are.

Making UR & Claims Determinations Easier for Healthcare Payers

If you're a utilization review or claims professional dealing with acute or chronic care populations, you probably deal with lots of cases that fall outside your normal criteria or plan language, and into the "gray zone." As you know, the standards of care are rapidly changing with emerging medical treatments, new technologies , drugs, etc. As a managed care professional, it's impossible to stay up on all of the latest changes in care management. What to do?

We've created a publication called "The Cutting Edge," which is designed to help critical and complex claims professionals stay on top of changing standards of care. Each issue features articles written by top specialists who are experts in their respective fields, who are board certified and in active practice. In these articles, you'll find information that will help you make more informed retrospective and pre-certifications decisions, based on the latest medical evidence.

Interested in signing up to receive a free copy? Click here: http://www.allmedmd.com/peerpoints/cuttingedge/cutting_edge_form.htm

-AGR