DID CALIFORNIA LOSE $30,000,000 IN GENERAL FUND REVENUES?
Yes, indeed, asserts this author: here's how. The State of California gives away de facto licensure to practice medicine to out-of-state doctors who are not licensed in California. Since passage of SB 899 in California, insurance companies have had the right to seek utilization review (UR) from doctors who aren't licensed in California and who haven't done the 12-hour pain management course that is required of doctors licensed in California. Non-California licensed doctors are not held accountable for wrong-doing by the Medical Board of California since they're not licensed in this state. Neither are they reponsible to the medical boards of their own states since their own medical state boards don't have jurisdiction in California. This largesse has allowed insurance companies to retain utilization reviewers from out-of-state who are compliant with the interests of insurance and UR companies. These UR doctors don't pay fees to the medical board of California. Wrongful decisions which delay or deny care to injured workers conserve money for the insurance industry and reduce taxable income since providers of care don't have to be paid.
Protest has evolved. In 2008 Assemblywoman Sally Lieber presented AB 2968 which would have required licensure. The bill passed the legislature but Governor Schwarzenegger vetoed it. That veto is estimated to have caused California to lose about $10,000,000 in fees and taxable revenues that would have gone to the General Fund. Then Assemblyman Paul Fong presented AB 933 to accomplish the same goal. This bill also passed the legislature but Governor Schwarzenegger vetoed it again. So now the state was down another $10,000,000 for a total of $20,000,000. But Paul Fong got a second chance with AB 584 which also passed the legislature. The surprise came when Governor Brown vetoed it ostensibly because he didn't want piecemeal changes in workers comp legislation (although he approved piecemeal legislation in other areas). Now the state's loss was an estimated $30,000,000. Not to worry, of course, tax payers can always make up the loss.
COMES NOW AB 1687 (Fong) and AB 1848 (Atkins). Both bills offer corrective measures and deserve serious consideration. Fong's bill would require clear and concise language to explain delays or denials of care by utilization reviewers. It would not require California licensure. It would not require the out-of-state non-California licensed doctors to complete the 12-hour pain management course that is a requirement in law for licensed California doctors. All the same it is a step in the right direction. Atkins' bill is the stronger bill since it would require a specified level of certification and would bring the out-of-state doctors under the purview of the medical board of California. Its wording doesn't specify that these doctors would have to comply with the 12-hour pain management requirement. Both bills can still be amended further if the authors want it done.
Cave Canem (beware of the dog) Get it done lest the next time we turn around our state will have lost $40,000,000 -- not to worry, right? We tax payers always make up the difference.
Saturday, April 21, 2012
Wednesday, March 28, 2012
AFFORDABLE CARE ACT AND THE IPAB: whose sails should be trimmed?
THE INDEPENDENT PAYMENT ADVISORY BOARD (IPAB) of the Affordable Care Act (ACA) was written into the ACA to control costs. It is a regulatory mechanism included in the ACA to regulate the commerce that the ACA creates. Congress cannot reasonably argue that the ACA doesn't create commerce while at the same time inserting into the ACA a mechanism to regulate newly created commerce. The argument comes down to this point: either Congress has the right to create commerce or it does not.
As a regulatory mechanism, the IPAB will have the authority to deny access to care to methods of diagnosis and treatment prescribed by licensed physicians. The IPAB will not report to Congress nor to the population at large. As a politically appointed board the IPAB will report to the political persons who appointed them.
The Supreme Court of the United States (SCOTUS) could invalidate some but not all parts of the ACA which was characterized in court as consisting of over 2,000 pages which many members of Congress haven't read and don't understand. On the other hand, everyone understands that insurance companies, left to their own devices, have often arbitrarily denied forms of treatment or engaged in retroactive denials of care and coverage. Nobody trusts the insurance companies to do the right thing, least of all Congress which exempted itself from the ACA. A modest proposal would be to preclude retroactive denials of coverage and arbitrary utilization review by doctors who haven't interviewed and examined the patients for whom specific diagnostic and treatment protocols have been prescribed. Another modest proposal would be to repeal the IPAB.
The more radical proposals are to do away with the entire ACA which would strip away protection from denials of care based on pre-existing conditions, e.g., life, and which could also pave the way for wrongful denials of care especially to the poor and elederly and to Medicaid and Medicare in particular.
Both sides have in common a distrust of the insurance companies; however, the Justices are supposed to deal with issues of law, not justice. It is strange then, isn't it, that we already know how at least four of the justices will rule. We don't need law degrees to know that. Neither do the justices need medical degrees to know the consequences of their decisions about the accessibility of medical care.
References
See The Weinmann Report on POLITICO Forums, POLITICO.com, 3/28/2012, Reply # 43, http://dyn.politico.com/members/forums/thread.cfm?catid=1&su ...
As a regulatory mechanism, the IPAB will have the authority to deny access to care to methods of diagnosis and treatment prescribed by licensed physicians. The IPAB will not report to Congress nor to the population at large. As a politically appointed board the IPAB will report to the political persons who appointed them.
The Supreme Court of the United States (SCOTUS) could invalidate some but not all parts of the ACA which was characterized in court as consisting of over 2,000 pages which many members of Congress haven't read and don't understand. On the other hand, everyone understands that insurance companies, left to their own devices, have often arbitrarily denied forms of treatment or engaged in retroactive denials of care and coverage. Nobody trusts the insurance companies to do the right thing, least of all Congress which exempted itself from the ACA. A modest proposal would be to preclude retroactive denials of coverage and arbitrary utilization review by doctors who haven't interviewed and examined the patients for whom specific diagnostic and treatment protocols have been prescribed. Another modest proposal would be to repeal the IPAB.
The more radical proposals are to do away with the entire ACA which would strip away protection from denials of care based on pre-existing conditions, e.g., life, and which could also pave the way for wrongful denials of care especially to the poor and elederly and to Medicaid and Medicare in particular.
Both sides have in common a distrust of the insurance companies; however, the Justices are supposed to deal with issues of law, not justice. It is strange then, isn't it, that we already know how at least four of the justices will rule. We don't need law degrees to know that. Neither do the justices need medical degrees to know the consequences of their decisions about the accessibility of medical care.
References
See The Weinmann Report on POLITICO Forums, POLITICO.com, 3/28/2012, Reply # 43, http://dyn.politico.com/members/forums/thread.cfm?catid=1&su ...
Tuesday, March 27, 2012
CAN CONGRESS CREATE COMMERCE? That's the question that was asked today in the United States Supreme Court with reference to the Affordable Care Act.
While it was acknowledged that Congress can regulate commerce, it was not accepted that Congress can create commerce. The basic question is whether or not the creation of the Individual Mandate creates commerce. It is this concept, requiring persons to purchase a product, that opponents argue is a step too far. Can government require the purchase of specific products on the grounds that they're good for us, e.g., the now famous broccoli argument, or exercise. What would prevent government from requiring the purchase of this or that vegetable if it were deemed good for the general health? Why not require everyone to buy a gym membership and then police the purchasers to be sure they exercise? The argument is that so doing would be an unconstitutional extension of federal authority even if the argument that "it's good for you" is correct.
WHAT IF THE LAW IS STRUCK DOWN? Will we then get return to policies that allow disqualification from health insurance because of pre-existing conditions?
WHAT IF THE LAW IS UPHELD BUT THEN WE TURN OUT TO HAVE A SHORTAGE OF DOCTORS? A shortage of 20,000 primary care doctors is predicted over the next few years. To this question we have an answer, i.e., government will allow non-physicians to practice medicine by setting up alternative credentialing processes that will allow persons with "alternative credentials" to practice (after all, in stiff white laboratory coats don't they all look alike anyway?).
WHAT ABOUT PIECEMEAL DISMANTLING OR ENABLEMENT OF THE ACA? The court could rule in such a way that insurance companies are precluded from denying insurance to persons with pre-existing conditions. The court could throw out the Independent Payment Advisory Board (IPAB) which many of us see as a thinly veiled ruse to deny access to care without invoking formal rationing (see our previous columns wherein the IPAB as a cost-control mechanism is discussed).
SOME PUNDITS THINK THAT BOTH OBAMA AND ROMNEY ARE ON THE ROPES, Obama because the ACA is largely his doing, Romney because he developed a similar plan in Massachusetts. Although Romney is campaigning against the ACA on a federal level, he avers that so doing within individual states is a matter of states rights, not unlike mandatory automobile insurance. On the other hand, Obama has let several of his health-care promises slip away, e.g., "I will ensure that no government bureaucrat gets between you and the care you need."
The IPAB was inserted into the ACA for cost control, in short, to stand "between you and the care you need." But for now, the ringing question is whether or not cramming mandatory health insurance down our throats is a wise extension of government policy or an unconstitutional creation of commerce as opposed to a regulation of commerce. Stay tuned.
Reference
"What Obama should've said about health reform," Robert L. Weinmann, MD, THE HILL NEWSPAPER, Washington, DC, 16 September 2009
While it was acknowledged that Congress can regulate commerce, it was not accepted that Congress can create commerce. The basic question is whether or not the creation of the Individual Mandate creates commerce. It is this concept, requiring persons to purchase a product, that opponents argue is a step too far. Can government require the purchase of specific products on the grounds that they're good for us, e.g., the now famous broccoli argument, or exercise. What would prevent government from requiring the purchase of this or that vegetable if it were deemed good for the general health? Why not require everyone to buy a gym membership and then police the purchasers to be sure they exercise? The argument is that so doing would be an unconstitutional extension of federal authority even if the argument that "it's good for you" is correct.
WHAT IF THE LAW IS STRUCK DOWN? Will we then get return to policies that allow disqualification from health insurance because of pre-existing conditions?
WHAT IF THE LAW IS UPHELD BUT THEN WE TURN OUT TO HAVE A SHORTAGE OF DOCTORS? A shortage of 20,000 primary care doctors is predicted over the next few years. To this question we have an answer, i.e., government will allow non-physicians to practice medicine by setting up alternative credentialing processes that will allow persons with "alternative credentials" to practice (after all, in stiff white laboratory coats don't they all look alike anyway?).
WHAT ABOUT PIECEMEAL DISMANTLING OR ENABLEMENT OF THE ACA? The court could rule in such a way that insurance companies are precluded from denying insurance to persons with pre-existing conditions. The court could throw out the Independent Payment Advisory Board (IPAB) which many of us see as a thinly veiled ruse to deny access to care without invoking formal rationing (see our previous columns wherein the IPAB as a cost-control mechanism is discussed).
SOME PUNDITS THINK THAT BOTH OBAMA AND ROMNEY ARE ON THE ROPES, Obama because the ACA is largely his doing, Romney because he developed a similar plan in Massachusetts. Although Romney is campaigning against the ACA on a federal level, he avers that so doing within individual states is a matter of states rights, not unlike mandatory automobile insurance. On the other hand, Obama has let several of his health-care promises slip away, e.g., "I will ensure that no government bureaucrat gets between you and the care you need."
The IPAB was inserted into the ACA for cost control, in short, to stand "between you and the care you need." But for now, the ringing question is whether or not cramming mandatory health insurance down our throats is a wise extension of government policy or an unconstitutional creation of commerce as opposed to a regulation of commerce. Stay tuned.
Reference
"What Obama should've said about health reform," Robert L. Weinmann, MD, THE HILL NEWSPAPER, Washington, DC, 16 September 2009
Sunday, March 4, 2012
UTILIZATION REVIEW AND THE CALIFORNIA PROFESSIONAL FIREFIGHTERS
On 14 February 2012 Assemblyman Paul Fong introduced AB 1687 at the request of California Professional Firefighters. The purpose of the bill is to improve how Utilization Review (UR) is applied in California's workers comp system. Currently the UR process may be used by insurance companies to delay and deny care to injured workers. Doctors retained by the insurance companies and their affiliated UR companies are not required to have California licenses. If these doctors make mistakes, wrongfully deny care, and cause harm to injured workers, they do not answer to the Medical Board of California as would treating doctors, known as PTPs or Primary Treating Physicians, who are licensed in the states in which they practice.
Non-California licensed doctors do not answer to their own state boards because out-of-state medical boards do not have jurisdiction in California. Insurance companies derive financial benefits from this method because they don't pay for care that has been disallowed by the unlicensed doctors even if the care was actually prescribed by licensed doctors. This form of retroactive denial of care has previously been discussed in these pages.
Efforts to pass legislation to correct this situation by requiring UR doctors to be licensed in California have been successfully opposed by insurance companies who easily convinced Gov. Schwarzenegger to deny access to care to injured workers but who also persuaded Gov. Brown to veto AB 584 in 2011 (AB 584, also by Paul Fong, would have required UR doctors who do California cases to be licensed in California).
Fong's current bill, AB 1687, says that
Without this provision the UR doctor and the medical director employed by the UR company, in turn retained by the insurance company, may assert that whatever reason is presented for delay or denial of care is "clear and concise." The change in language requested by the California Professional Firefighter is a step in the right direction and deserves support even though it isn't strong enough to challenge wrongful and harmful decisions by non-California licensed doctors who can simply state that their reasons for delaying or denying care are "clear and concise."
Rather than get involved in debates about whether or not language was "clear and concise," beleagured doctors who prefer to practice medicine will leave the system. The large clinics that see patients at breakneck speed will inherit the patients. Injured workers will once again inherit the wind.
Non-California licensed doctors do not answer to their own state boards because out-of-state medical boards do not have jurisdiction in California. Insurance companies derive financial benefits from this method because they don't pay for care that has been disallowed by the unlicensed doctors even if the care was actually prescribed by licensed doctors. This form of retroactive denial of care has previously been discussed in these pages.
Efforts to pass legislation to correct this situation by requiring UR doctors to be licensed in California have been successfully opposed by insurance companies who easily convinced Gov. Schwarzenegger to deny access to care to injured workers but who also persuaded Gov. Brown to veto AB 584 in 2011 (AB 584, also by Paul Fong, would have required UR doctors who do California cases to be licensed in California).
Fong's current bill, AB 1687, says that
"communications or responses regarding decisions to modify, delay, or deny medical treatment services requested by physicians also shall include a clear and concise explanation of the available options for objecting to the modification, delay, or denial of those medical services."It does not say that the UR doctors who make these decisions should be licensed in California. This omission is the Achilles' heel of AB 1687.
Without this provision the UR doctor and the medical director employed by the UR company, in turn retained by the insurance company, may assert that whatever reason is presented for delay or denial of care is "clear and concise." The change in language requested by the California Professional Firefighter is a step in the right direction and deserves support even though it isn't strong enough to challenge wrongful and harmful decisions by non-California licensed doctors who can simply state that their reasons for delaying or denying care are "clear and concise."
Rather than get involved in debates about whether or not language was "clear and concise," beleagured doctors who prefer to practice medicine will leave the system. The large clinics that see patients at breakneck speed will inherit the patients. Injured workers will once again inherit the wind.
Monday, February 27, 2012
UTILIZATION REVIEW (UR) BY NON-CALIFORNIA LICENSED DOCTORS
AB 1687 (Fong) misses the target
AB 1687 states that employers, insurers, or other entities shall employ or designate medical directors who hold unrestricted California licensure to practice medicine in California pursuant to the relevant Business and Professions Codes.
However, it is already law that the medical director must be licensed in California. What is not required is that the doctors retained by the medical director to do utilization review (UR) also be licensed in California. The currently proposed bill overlooks this loophole by not mentioning the inconvenient fact that companies may use doctors without California licenses even though the Medical Board of California has repeatedly stated that UR is part of medical practice. What is needed is a requirement that any doctor who does utilization review in California must be licensed to practice in California. Language so stating should be amended into the bill.
The crux of the issue in past years was precisely this point. The insurance companies skillfully and successfully opposed requiring California state licensure for UR doctors. Three bills so stating have passed the California legislature: AB 2969 (Lieber), AB 933 (Fong), and AB 584 (Fong). The first two were vetoed by Governor Schwarzenegger, no surprise there since his mission was to protect the insurance companies. The last one was vetoed by Governor Brown, much to the astonishment of many who did not think he'd bend to insurance company wishes. However, lobbying credit has to go to the insurance companies -- they succeeded in convincing two different and supposedly opposed administrations to veto nearly identical bills that would have assisted injured workers' access to care.
Our judgement is that AB 1687 is inadequate and disappointing. We await an amendment stating that UR doctors play by the same rules as treating doctors and must be licensed to practice in California.
Stay tuned. We'll have more to say on this subject.
AB 1687 states that employers, insurers, or other entities shall employ or designate medical directors who hold unrestricted California licensure to practice medicine in California pursuant to the relevant Business and Professions Codes.
However, it is already law that the medical director must be licensed in California. What is not required is that the doctors retained by the medical director to do utilization review (UR) also be licensed in California. The currently proposed bill overlooks this loophole by not mentioning the inconvenient fact that companies may use doctors without California licenses even though the Medical Board of California has repeatedly stated that UR is part of medical practice. What is needed is a requirement that any doctor who does utilization review in California must be licensed to practice in California. Language so stating should be amended into the bill.
The crux of the issue in past years was precisely this point. The insurance companies skillfully and successfully opposed requiring California state licensure for UR doctors. Three bills so stating have passed the California legislature: AB 2969 (Lieber), AB 933 (Fong), and AB 584 (Fong). The first two were vetoed by Governor Schwarzenegger, no surprise there since his mission was to protect the insurance companies. The last one was vetoed by Governor Brown, much to the astonishment of many who did not think he'd bend to insurance company wishes. However, lobbying credit has to go to the insurance companies -- they succeeded in convincing two different and supposedly opposed administrations to veto nearly identical bills that would have assisted injured workers' access to care.
Our judgement is that AB 1687 is inadequate and disappointing. We await an amendment stating that UR doctors play by the same rules as treating doctors and must be licensed to practice in California.
Stay tuned. We'll have more to say on this subject.
Sunday, February 26, 2012
"WHAT WE DON'T WANT IS PEOPLE MAKING ... DECISIONS BASED ON MONEY INSTEAD OF CARE OF THE TROOPS," intoned Representative Norman Dicks, D-Belfair
In our previous column we discussed how insurance companies can twist policies and distort the Affordable Care Act so that denials of care replace rationing. Now we have a situation wherein an actual diagnosis is rationed if not tossed to the winds, i.e., medical treatment for post-traumatic stress disorder (PTSD) in military veterans. This diagnosis can cost from $400,000 to $1.5 million in lifetime benefits.
Rep. Norm Dicks asked Army Surgeon General Lt. Gen. Patricia Horoho to explain how 14 soldiers diagnosed with PTSD had their diagnoses retroactively changed by a forensic psychiatry team in such a manner as to reduce the veterans' disability benefits.
This method replaces actual rationing of care because it allows forensic personnel concerned with costs to overturn a medical diagnosis upon which actual treatment was based. The implication is that the injured soldiers were incorrectly treated and were then awarded excessive benefits.
Keep in mind that the so-called forensic team does not interview and examine the patients -- what they do is a coding audit to determine if the submitted paperwork justifies the diagnosis. Here's an example: post-concussion head syndrome, not a PTSD diagnosis per se, is listed as ICD-9 code 310.2. This diagnosis may include headaches, vertigo and cognitive loss. But if the paperwork reflects headache such that a forensic team can claim with a modicum of reasonable medical probability that the formal diagnosis of 301.2 wasn't fully documented, the diagnosis can be altered to one less remunerative in terms of treatment and disability benefits, e.g., headache, 784.0 -- in this way the payer, whether government or a private insurance company, saves money, increases corporate compensation for the private insuror, and puts the screws to the injured party, a private patient or a wounded soldier.
While we appreciate Rep. Dicks' intervention for the soldiers, we ask where he stands on repeal of the Independent Payment Advisory Board (Section 10320) which is part of the Affordable Care Act for which readers will want to know how Dicks voted. Our expectation is that Rep. Dicks cares as much about Medicare recipients and patients generally as he does about PTSD veterans and their disability remuneration.
If Rep. Dicks wants to stop the deprivation of disabiity benefits to sick and injured soldiers, he just might want to do as much for sick and injured civilians. So might also my own Congressional representantive, Anna Eshoo, D-Ca.
How about it, Norm, Anna, and all other Members of Congress?
References
"Rationing Comes Home to Roost in the Form of Denial of Care," posted originally on www.politicsofhealthcare.com, 2/17/12, reprinted workcompcental, 2/24/12
"Army insists doctors at Madigan aren't discouraged from diagnosing PTSD," The News Tribune, by Adam Ashton, 2/10/12
"Head of Madigan removed from command admid PTSD probe," Seattle Times," 2/20/12, by Hal Bernton
Rep. Norm Dicks asked Army Surgeon General Lt. Gen. Patricia Horoho to explain how 14 soldiers diagnosed with PTSD had their diagnoses retroactively changed by a forensic psychiatry team in such a manner as to reduce the veterans' disability benefits.
This method replaces actual rationing of care because it allows forensic personnel concerned with costs to overturn a medical diagnosis upon which actual treatment was based. The implication is that the injured soldiers were incorrectly treated and were then awarded excessive benefits.
Keep in mind that the so-called forensic team does not interview and examine the patients -- what they do is a coding audit to determine if the submitted paperwork justifies the diagnosis. Here's an example: post-concussion head syndrome, not a PTSD diagnosis per se, is listed as ICD-9 code 310.2. This diagnosis may include headaches, vertigo and cognitive loss. But if the paperwork reflects headache such that a forensic team can claim with a modicum of reasonable medical probability that the formal diagnosis of 301.2 wasn't fully documented, the diagnosis can be altered to one less remunerative in terms of treatment and disability benefits, e.g., headache, 784.0 -- in this way the payer, whether government or a private insurance company, saves money, increases corporate compensation for the private insuror, and puts the screws to the injured party, a private patient or a wounded soldier.
While we appreciate Rep. Dicks' intervention for the soldiers, we ask where he stands on repeal of the Independent Payment Advisory Board (Section 10320) which is part of the Affordable Care Act for which readers will want to know how Dicks voted. Our expectation is that Rep. Dicks cares as much about Medicare recipients and patients generally as he does about PTSD veterans and their disability remuneration.
If Rep. Dicks wants to stop the deprivation of disabiity benefits to sick and injured soldiers, he just might want to do as much for sick and injured civilians. So might also my own Congressional representantive, Anna Eshoo, D-Ca.
How about it, Norm, Anna, and all other Members of Congress?
References
"Rationing Comes Home to Roost in the Form of Denial of Care," posted originally on www.politicsofhealthcare.com, 2/17/12, reprinted workcompcental, 2/24/12
"Army insists doctors at Madigan aren't discouraged from diagnosing PTSD," The News Tribune, by Adam Ashton, 2/10/12
"Head of Madigan removed from command admid PTSD probe," Seattle Times," 2/20/12, by Hal Bernton
Friday, February 17, 2012
RATIONING COMES HOME TO ROOST IN THE FORM OF DENIALS OF CARE
In these columns (www.politicsofhealthcare.com) we've previously pointed out how Utilization Review in California is twisted and turned to deny care to injured workers. We've also shown how the Affordable Care Act, aka Obamacare, contains a not-so-subtle rationing section known as the Independent Payment Advisory Board (IPAB) pursuant to Section 10320 of the ACA.
What's next on the Denial Menu is a method to deny care not only to injured workers and Medicare recipients, but to anyone, anywhere, anytime. The insurance companies are adopting plans based on science but far from scientific. Here's how such plans work and how they'll be used in compliance with the ACA.
Currently, insurance companies are allowed to warn subscribers about medications, adverse effects of medications, and how some medications may have ill effects if combined with certain other medications or substances. In the media limelight just now is how xanax and alcohol if taken together may prove fatal.
The program seems protective; however, practicing physicians know how insurance companies use this concept to push generic medications over trade-name products that treating physicians feel are superior or to deny a recommended treatment for another that costs less.
Practicing physicians have also observed that specific treatments with comparatively lower levels of success than others, sometimes the best bet for certain patients, may be denied because their overall success rate is less than a pre-designated level of success, say, 50%. But in some patients there may not be a better choice.
Delay and Denial Menus (DADMs)
This concept is being used to deny or delay diagnostic and treatment protocols, e.g, tests physicians use to decide upon diagnosis and regulate treatment. These Delay and Denial menus mean that insurance companies will not be obliged to pay for tests or treatments that don't measure up to internal business protocols that need not be explained or even made known to the public or to the companies' own subscribers. Here's how it'll work:
Insurance Company UltraNix may give its own grades to various diagnostic tests and treatments. Those tests and treatments graded "A" or "B" will get covered, e.g., maybe 100% for "A," maybe 75% for "B," maybe less for "C," and not at all for "D." The cut-off levels are decided by the insurance companies. Most likely to be effected will be cancer screening and other conditions where the last scientific word hasn't yet been written. One may reasonably ask why insurance companies shouldn't wait for the last scientific word. The answer is that science is slow, e.g., aspirin for protection from heart disease wasn't fully accepted until comparatively recently although medical and scientific data in support of this use was already in circulation for many years.
Because of the ACA such restrictions which amount to rationing may now enjoy the force of law despite President Obama's solemn promise in the autumn of 2009 that "I will ensure that no government bureaucrat gets between you and the care you need."
The restrictions shoved down subscribers' throats will not be subject to debate, disclosure, or revision -- these restrictions will be equivalent to "black box" recommendations just as those made by the Independent Payment Advisory Board (IPAB) even though President Obama recently promised in his State of the Union address that "I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny your coverage or charge women differently."
One result of the ACA is to permit insurance companies to adopt measures to restrict benefits without actually cancelling policies. If insurance companies can deny claims based on internal protocols of their own and not cancel policies, they'll have the best of both worlds, i.e., your premiums and no obligation to pay out on claims for diagnostic tests, treatment protocols, or medicines.
One caveat: the insurance companies will be off-the-hook only with reference to paying for the diagnostic test or treatment that one's doctor may have prescribed. Patients who want to pay 100% for something that their insurance companies have refused to cover will still be able to do so.
If this concept sounds like a scam, that's because it is. What is sad is that it fits into the Affordable Care Act which allows for precisely those denials of care that President Obama said he would not tolerate.
Other References by Robert L. Weinmann, MD
San Jose Business Journal, week of August 3, 1987 ("... it is our business to know which contracts our doctors sign"
San Jose Mercury News, April 2, 1993, "Managed care: the dark side" ("... the plan's doctors ... agree that the diagnostic tests and treatment plans they may prescribe may be abbreviated or disallowed by the plan's cost controllers")
Congressional Record, May 27, 1993 (above, reprinted, with comment from Pete Stark, MOC, D-CA)
San Francisco Examiner, January 12, 1996, "Medical red-lining :'Economic credentials' for physicians"
Congressional Record, 9 September 1998 (above, reprinted, with comment from then MOC Tom Campbell, R-CA)
The Hill, Washington, DC, 9/16/09, "What Obama should've said about health reform"
POLITICO, 12/14/2010, Washington, DC, "How to ration care without using the 'R' word"
POLITICO, 01/18/2011, Washington, DC, "Section 10320 of the Affordable Care Act Should Be Repealed First"
POLITICO, 07/14/2011, Washington, DC, "GOP dilemma: How to oppose IPAB: The Independent Payment Advisory Board (IPAB) is bad for your health"
The Hill, Washington, DC, 12/02/12, "Patient advisory board will put cost before care"
In these columns (www.politicsofhealthcare.com) we've previously pointed out how Utilization Review in California is twisted and turned to deny care to injured workers. We've also shown how the Affordable Care Act, aka Obamacare, contains a not-so-subtle rationing section known as the Independent Payment Advisory Board (IPAB) pursuant to Section 10320 of the ACA.
What's next on the Denial Menu is a method to deny care not only to injured workers and Medicare recipients, but to anyone, anywhere, anytime. The insurance companies are adopting plans based on science but far from scientific. Here's how such plans work and how they'll be used in compliance with the ACA.
Currently, insurance companies are allowed to warn subscribers about medications, adverse effects of medications, and how some medications may have ill effects if combined with certain other medications or substances. In the media limelight just now is how xanax and alcohol if taken together may prove fatal.
The program seems protective; however, practicing physicians know how insurance companies use this concept to push generic medications over trade-name products that treating physicians feel are superior or to deny a recommended treatment for another that costs less.
Practicing physicians have also observed that specific treatments with comparatively lower levels of success than others, sometimes the best bet for certain patients, may be denied because their overall success rate is less than a pre-designated level of success, say, 50%. But in some patients there may not be a better choice.
Delay and Denial Menus (DADMs)
This concept is being used to deny or delay diagnostic and treatment protocols, e.g, tests physicians use to decide upon diagnosis and regulate treatment. These Delay and Denial menus mean that insurance companies will not be obliged to pay for tests or treatments that don't measure up to internal business protocols that need not be explained or even made known to the public or to the companies' own subscribers. Here's how it'll work:
Insurance Company UltraNix may give its own grades to various diagnostic tests and treatments. Those tests and treatments graded "A" or "B" will get covered, e.g., maybe 100% for "A," maybe 75% for "B," maybe less for "C," and not at all for "D." The cut-off levels are decided by the insurance companies. Most likely to be effected will be cancer screening and other conditions where the last scientific word hasn't yet been written. One may reasonably ask why insurance companies shouldn't wait for the last scientific word. The answer is that science is slow, e.g., aspirin for protection from heart disease wasn't fully accepted until comparatively recently although medical and scientific data in support of this use was already in circulation for many years.
Because of the ACA such restrictions which amount to rationing may now enjoy the force of law despite President Obama's solemn promise in the autumn of 2009 that "I will ensure that no government bureaucrat gets between you and the care you need."
The restrictions shoved down subscribers' throats will not be subject to debate, disclosure, or revision -- these restrictions will be equivalent to "black box" recommendations just as those made by the Independent Payment Advisory Board (IPAB) even though President Obama recently promised in his State of the Union address that "I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny your coverage or charge women differently."
One result of the ACA is to permit insurance companies to adopt measures to restrict benefits without actually cancelling policies. If insurance companies can deny claims based on internal protocols of their own and not cancel policies, they'll have the best of both worlds, i.e., your premiums and no obligation to pay out on claims for diagnostic tests, treatment protocols, or medicines.
One caveat: the insurance companies will be off-the-hook only with reference to paying for the diagnostic test or treatment that one's doctor may have prescribed. Patients who want to pay 100% for something that their insurance companies have refused to cover will still be able to do so.
If this concept sounds like a scam, that's because it is. What is sad is that it fits into the Affordable Care Act which allows for precisely those denials of care that President Obama said he would not tolerate.
Other References by Robert L. Weinmann, MD
San Jose Business Journal, week of August 3, 1987 ("... it is our business to know which contracts our doctors sign"
San Jose Mercury News, April 2, 1993, "Managed care: the dark side" ("... the plan's doctors ... agree that the diagnostic tests and treatment plans they may prescribe may be abbreviated or disallowed by the plan's cost controllers")
Congressional Record, May 27, 1993 (above, reprinted, with comment from Pete Stark, MOC, D-CA)
San Francisco Examiner, January 12, 1996, "Medical red-lining :'Economic credentials' for physicians"
Congressional Record, 9 September 1998 (above, reprinted, with comment from then MOC Tom Campbell, R-CA)
The Hill, Washington, DC, 9/16/09, "What Obama should've said about health reform"
POLITICO, 12/14/2010, Washington, DC, "How to ration care without using the 'R' word"
POLITICO, 01/18/2011, Washington, DC, "Section 10320 of the Affordable Care Act Should Be Repealed First"
POLITICO, 07/14/2011, Washington, DC, "GOP dilemma: How to oppose IPAB: The Independent Payment Advisory Board (IPAB) is bad for your health"
The Hill, Washington, DC, 12/02/12, "Patient advisory board will put cost before care"
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