Driving An Insurance Exchange in 2014 - A Conversation From the Future

On some weekends, the Disease Management Care Blog listens in on a certain car-themed National Public Radio call-in show that features the often entertaining and sometimes helpful advice of two wacky automotive repairmen brothers.

They’re the inspiration for this futuristic posting on another Golden Boy of health reform called “insurance exchanges”…..

Click: ….. and that’s why the answer to this week’s puzzler is that you have to cut the banana in half and then divide it into thirds! But now its time for another caller.

Caller: Hello, my name is Marcie and I’m calling from Lake Nogebow, Illinois.

Click: Hello Marcie. What’s on your mind?

Marcie: Well, I drive a 2014 Insurance Exchange and it's driving me crazy. I can’t get it out of first gear and it will only go to one place no matter how I much I turn the wheel!

Clack: Hey, that’s what my wife says about me nyuck nyuck nyuck!

Click: Marcie, I have bad news. You’re not driving a "Fix It Again Tony" or FIAT, you’re driving a DIAB or a Defund It Again Boehner! That jalopy may need to be junked!

Marcie: Oh no, my State paid millions of dollars for it!

Clack: My wife paid nothing for me, so what a good deal for her nyuck nyuck nyuck!

Click: Well Marcie, Insurance Exchanges were manufactured using parts made in Massachusetts using European engineering. That's a really bad combo.

Clack: And we know nothing good comes out of Massachusetts, just look at my brother!

Click: Unfortunately, it’s impossible to adjust the innovation to actuarial equivalence ratios anywhere in the drivetrain. There’s a shortage of new insurance design parts and drivers can’t read any of the dials to easily compare one insurance plan to another!

Marcie: So that’s why I can’t steer my Exchange to a benefit design that I want or that I can afford....

Click: That’s right Marcie. This is just like the government’s approach to electric cars: you can have any kind you want, any style you want with any features you want so long as it’s a Chevy Volt.

Marcie: Oh, my wife is going to be so mad!

Click: There was good advice back in 2010, like this from the Brookings Institution that was published in the American Journal of Managed Care. Those heavy weight authors recommended that Insurance Exchanges be specifically configured to promote a wide array of innovative benefit plan designs. In addition, they argued that Exchanges need to provide consumer-friendly information on quality, cost and patient experience information. The Disease Management Care Blog also warned its readers, but few in government seemed to think about it.

Clack: When the subsidized public option was inserted in the engine, it was all over nyuck nyuck nyuck!

Marcie: So that's why I can only go to one place in it!

Click: You're right. Since the government ultimately decided which insurers appeared on the exchange and the decision logic favored the public option, "crowd out" happened faster than an Obama tax-cut veto.

Marcie: So what should I do?

Click: Now that's a puzzler!

"Care and Cost"

Good friends David Kibbe and Brian Klepper have finally started their own blog--aimed at becoming a forum for many contributors to the health care debate.I suggest you add, "Care and Cost"––"Health Care Conversations About Hard Choices and Emerging Solutions" to your bookmarks.

Disease Management, ie Population Health Management Organizations (PHMOs): Plan B to Support the Creation of the Patient Centered Medical Home (PCMH)

As the Disease Management Care Blog has previously pointed out, there is is a lot that the disease management industry has to offer the Patient Centered Medical Home (PCMH). That's why it agrees with this webinar summary that appeared in the latest issue of Population Health Management.

In it, Darren Schulte MD of Alere points out that expectations for the PCMH are very high. Its value proposition includes reversing the decay of primary care, meeting the consumerist needs of an aging population, increasing quality and securing additional practice income. A growing body of evidence suggests that the more successful PMCHs have 1) a dedicated non-physician patient coordinator, 2) expanded in-person and virtual patient access, 3) health information technology that includes a functioning registry and point-of-care decision support and 4) increased practice income. Without these key ingredients, PCMHs have an uphill battle managing a population of patients, building a team-based culture and marshaling resources to change patient behavior.

Enter disease management vendors, although Dr. Schulte prefers to use the politically correct term "population health management organizations" (PHMOs) They have decades of experience in patient education, monitoring, self management, treatment adherence and care coordination. Despite physician skepticism and a cultural bias that favors "build" over "buy," he argues that PCMHs may find PHMOs attractive not only because they're speaking the same language, but because their services are "plug n' play" and highly adaptable across a wide variety of small to large settings. All that needs to be worked is out how PHMO support will be paid for so that the PCMH succeeds.

Enter Dr. Greg Sharp of Ideal Family Healthcare in Woodland Park, CO. He notes that health insurers have a key role to play because they're not only providing the additional monthly payments for the PCMH, but they're being called on to support health information technology solutions and provide work-flow consultation services. Since insurers are very involved anyway, he implies that it's not a great leap form them to also facilitate the sponsorship of PHMOs in the PCMH network. Once that happens, he sees few barriers standing in the way of PCMH team members virtually working with remote or in-person PHMO health coaches, accessing the PHMO's registries and relying on PHMO decision support tools.

The acronym addled DCMB likes this description of how insurer sponsored PHMOs can help PCMHs. For a fiduciary and risk-bearing health insurer, the DMCB agrees that the road to patient behavior change, prevention and savings in medical homes may run through disease management. The DMCB suspects many primary care practices won't necessarily want to create (training the non-physicians in behavior change and coaching?) or be able to afford (buying the hardware and programming expertise to create a fully functioning registry?) all the features of a fully transformed PCMH. Calling it "PHMO" instead of using the scorned term "disease management" will also increase its acceptability.

Smart health insurers will recognize that there will be primary care sites that want to go their own way in establishing PCMHs. That's fine. For those primary care sites that may not have the resources or the inclination to build a fully functioning PCMH, bringing in a "population health management organization" vendor is a good Plan B. That disease management Plan B is a rose that by any other name still smells as sweet in the science of increasing quality and optimizing costs.

The Definition of Medical Necessity and Using It When Dealing With Health Insurers

Physicians, meet Mrs. "Smith." She's undoubtedly resembles many of your own patients. Like them, she is very frail and has more than her fair share of chronic conditions. Thanks to your diligent care, she has a good chance of seeing her great granddaughter this summer and, if the both of you are lucky, she won't see the inside of a hospital for years to come.

Unfortunately, however, the times they are a changin'. Mrs. Smith's health insurance may no longer "cover" your referral for a specialist consultation, your order for a expensive radiological imaging study or your prescription for a new medication. That's because she has been caught up in a thicket of shifting benefit designs, utilization management initiatives and coverage exclusions. Dealing with her insurance company is a maze-like exercise in professional frustration that sucks the joy out of medical practice faster than salaried docs exiting an Urgent Care Clinic at the end of their shift.

When the DMCB teaches, lectures and provides conferences for young physicians and medical students, it says the fix for Mrs. Smith's dilemma is two-fold.

First of all, it says, physicians need to familiarize themselves with the basics of health insurance. Once docs understand risk transfer, underwriting, trending, contracts, reserving, surplus management and regulatory oversight, the DMCB thinks they'll be better able to advocate on behalf of their patients at both a local and national level. That will take time and effort. It's too important to leave to the experts. One good way to deal with that is for docs to regularly read the DMCB.

Secondly, docs need to learn to use the words "medical necessity." This is one of those basics described above that, if raised at the right time when dealing with an uncooperative health insurer, is more likely to get Mrs. Smith the coverage for the services.

Medical necessity is a key concept used by insurers and regulators to describe any health care intervention that is:

(a) recommended by the health care provider;
(b) treatment for a medical condition;
(c) at an appropriate level of service or supply
(d) considered to be effective in improving health outcomes, as determined by scientific evidence, accepted standards of medical practice, or, expert opinion
(e) cost-effective for this condition compared to alternative interventions
(f) not solely for the covered person’s convenience or the convenience of the covered person’s family or physician.

While there are exceptions, health insurers are obliged to cover all medically necessary services.

The DMCB recognizes that calling an insurer's 800 number, faxing copies of medical records, completing preauthorization forms and tabbing through a web site can a dreadful and demeaning experience. That's not the point. The point is that, a live employee of the insurer is going to have to eventually read or listen to what you have to say. Physicians' chances of prevailing on behalf of Mrs. Smith will be significantly increased if that employee hears or reads the words "medically necessary" somewhere in the course of your appeal. If they know that you can argue the merits on that basis, your chances on behalf of Mrs. Smith will improve.

How not to deal with an initial denial for payment coverage for a CAT scan:

"I want to rule out a tumor, so I need this imaging study stat. Please approve"

A better way to deal with that denial for a CAT scan:

"As a physician, I've determined that this patients' new symptom of pain could be consistent with a diagnosis of cancer. A CAT scan is the best first step imaging study to address this possibility based on my professional judgment and prevailing practice standards. There is no reasonable alternative imaging modality or other option to adequately address the diagnosis. I and my patient look forward to hearing from you shortly about coverage for this medically necessary service."

Grand Rounds Is Up and the Disease Management Care Blog Is Included

The Disease Management Care Blog has never ever been in "Grand Rounds," a compendium of recent blog posts that deal with medical topics. This one has links to posts about thyroidectomies, the practice of internal medicine, the medical implications of airport body scanning as well as a posts dealing with the various impacts of policy making on the practice of medicine. The DMCB is still working its way through all the great reading. It's well worth your time.

A New Cavalcade of Risk Is Up!

This one is ably hosted by newbie Nina Kallen, a lawyer specializing in insurance law. She does a great job of summarizing some important topics that make for interesting reading. As an added bonus, she doesn't disagree with the DMCB.

It's worth a look so check it out.

speaks to me

Thank you xkcd.