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Employers have joined the nation’s health plans to simplify the way they evaluate health plans’ requests for information. New guidelines released by the American Association of Health Plans (AAHP) and the Employers’ Managed Health Care Association (EMHCA) both based in Washington, DC, should reduce costs for employers and health plans while at the same time improving the data used to select health plans.
Data collection is an expensive process, yet one health plan recently reported receiving an RFI requesting 220,000 data points, according to AAHP. To make matters worse, only about 10% to 15% of questions are common to multiple RFIs. "Especially at a time of great concern about health care costs, we had to find a better way to get in-depth health plan data that would be less costly and less burdensome to plans and employers alike," explains Dwaine Hartline, EMHCA’s board president.
The new guidelines have already received wide support from business leaders and benefits administrators, report the sponsoring organizations. The result should be to produce information that can better compare plans, while dramatically reducing costs spent to prepare and analyze such data. The guidelines address the following four areas:
Notice: If you want to do case management for the Ohio Bureau of Workers’ Compensation (BWC) in Columbus, you must be accredited by the URAC/American Accreditation HealthCare Commission in Washington, DC, by the end of 2002.
BWC, which is both the regulator of workers’ compensation and the administrator of the state risk-pool for injured employees, now requires managed care organizations (MCOs) it contracts with for medical management and return-to-work services to receive URAC’s Case Management Organization Accreditation. In a new contract sent to more than 30 MCOs, the BWC advised them to "apply for URAC case management accreditation no later than Dec. 31, 2001" and to "use [their] best efforts to obtain URAC case management accreditation no later that Dec. 31, 2002."
"One of the advantages we see in having our MCOs URAC-accredited," notes BWC representative Diana Cline, "is that it’s an independent accrediting body reviewing our MCOs’ case management programs, which Ohio views as critical in providing quality services for our injured workers. An independent review is very important to us."
For more information, contact Cline at (614) 466-8269, or e-mail her at email@example.com.
The debate over passage of a patient’s bill of rights still rages and case managers in managed care plans should pay close attention to the anti-managed care rhetoric of health care advocates as they lobby legislators to ensure their interests are well represented when the final draft becomes law. During recent hearings on Capitol Hill, officers of the American Medical Association (AMA) in Chicago told Congress that HMOs, like every other entity in our society, must be held accountable for harm they do to patients.
"It simply isn’t fair to grant a shield of immunity to health plans — a shield not given to any other person or business entity," argued AMA trustee Donald J. Palmisano, MD, before the House Energy and Commerce Health Subcommittee.
The majority of Americans seem to agree with this sentiment. A January Kaiser/Harvard poll found that 75% of Americans support patient protections, including the right to sue health plans. "There is no sound policy reason why we should leave injured patients with no real legal remedy when they have been injured by a negligent health plan," Palmisano told House subcommittee members. "This is truly an issue of fundamental fairness."
Federal judges also have called on Congress to fix the problem, Palmisano said, noting that "because states historically have retained jurisdiction to govern the practice of medicine, if the case involves a medical judgment the plan has made, then the case should go to state court. It’s that simple."
The Judicial Conference of the United States, headed by Chief Justice William Rehnquist, has urged Congress to use state courts as "the primary forum for the resolution of personal injury claims arising from the denial of health care benefits."
Palmisano urged Congress to pass a strong patients’ bill of rights, saying "President Bush has stated repeatedly that the patient protection laws in Texas are working well. Despite the insurance industry’s claims, health care costs have not skyrocketed; employers have not suddenly dropped health benefits; and patients trying to file frivolous lawsuits have not overrun the courts. We (the members of the AMA) call on Congress to help pass a meaningful, bipartisan patients’ bill of rights this year."
Patients, employers, and physicians have found some common ground, according to a recently released poll from the American Association of Health Plans (AAHP) in Washington, DC. It seems all three groups prefer an independent medical appeals process over lawsuits as a means of resolving disputes over medical coverage.
In addition, the poll of 400 physicians finds that America’s physicians think the medical liability system has damaged the practice of medicine. In particular, physicians report that the current liability system raises medical costs, hurts the doctor-patient relationship, leads to defensive medicine, and reduces the reporting of medical errors.
Specific findings include:
• 75% of physicians favor giving an independent physician appeals panel the power to resolve disputes with health plans over coverage, whereas 17% prefer to give patients the option to sue their health plans for damages.
• 73% of physicians prefer a bill with an independent appeals process compared to 20% who believe that no bill should be passed unless new lawsuits are included.
The results of the physician poll mirror those of a poll of 1,000 voters conducted last November by AAHP. A copy of the survey in PDF format is available on-line at www.aahp.org/aahp/redirect/summary.pdf.