Insurance industry and DxError reduction: partnership opportunities

Lorri Zipperer Lorri at ZPM1.COM
Fri Apr 17 13:29:06 UTC 2015


Thanks for mentioning this Rob.

 

I’ll remind folks that CNA Insurance was a founding sponsor of the National Patient Safety Foundation. They helped us get off the ground. As did the American Medical Association and Schering Plough. 

 

We need to consider all partners in this work – can’t let biases and mental models get in the way of moving forward ;-)

 

Lorri

 

Lorri Zipperer, Cybrarian

Zipperer Project Management

lorri at zpm1.com

www.zpm1.com

http://www.facebook.com/pages/Zipperer-Project-Management/182163928471320

http://dbiosla.org/development/systems/index.html

http://patientsafetylib.blogspot.com/

http://www.linkedin.com/groups?gid=4412282

Skype: lzipperer

LinkedIn Group / Patient Safety Partners: 

http://www.linkedin.com/groups?gid=163248

 

"The person who says it cannot be done should not interrupt the person doing it" Chinese Proverb

 

From: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG] 
Sent: Thursday, April 16, 2015 9:01 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error

 

Xavier,

 

I am not sure that I totally agree.

 

All peoples in the Healthcare industry, as you mention including physicians, have biases.

 

Would it not be considered a good thing for patients If insurance industry biases lead to less errors in medicine and reduced litigation costs?

 

The Insurance Industry has a fairly good record in sponsoring educational events in an attempt to reduce errors.

 

Rob Bell 

 

 

On Apr 14, 2015, at 11:31 AM, Xavier Prida <dr.xavier.prida at GMAIL.COM> wrote:

 

Insurance companies should not have even a subordinate role, in that they possess the identical conscious or unconscious, intentional or unintentional bias conflict of interest(COI) of a fiduciary responsibility to the shareholders of the corporation(identical biases that physicians have in a fee for service environment-but opposite incentive).

 

On Tue, Apr 14, 2015 at 11:30 AM, Jackson, Brian <brian.jackson at aruplab.com> wrote:

There’s an important point in this thread that I want to call out.  Health insurance companies are NOT the right entity to play the main role in ensuring high quality care.  They’ve only stepped into that role because clinical care delivery entities (medical groups, hospitals, etc.) haven’t fully owned it.  And I suspect this is largely because of a misunderstanding of the role of professionalism.

Utilization reviewers working for insurers will never be in a good position to assess clinical quality because they’re organizationally too distant from the point of care.  What we need instead are more front-line leadership roles filled by experienced doctors who supervise their peers, reporting up to clinically-trained top-level leaders.  In an ideal world, insurance companies would play a subordinate role.  Or to paraphrase a VP at Intermountain Health Care (I forget his name), health insurers should own actuarial risk (who gets what diseases) and healthcare delivery systems should own medical risk (how much value is delivered to those patients).

--Brian Jackson

From: Phillip Benton [mailto:0000000697ec7b18-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG] 
Sent: Monday, April 13, 2015 3:23 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error

Rob & Mark,

Yes, theoretically the insurance carrier should be the primary filter, but most of the reviewer's who pre-certify (approve/turn down) surgery requested have little or no formal medical education, and operate strictly from a computer screen that lists what they will or will not approve for a certain diagnosis. Whether it is unnecessary or excessive at that point in time (with so little symptomatic disease, confirmed by appropriate studies) is outside their discretion.

'Second Opinion' also falls short of controlling inappropriate or unnecessary surgery (see L. Leape, attached). In small communities, friends may approve each other's cases without the insurors' knowledge. Some specialty societies, such as North American Spine Society, are working actively to establish 'surgical appropriateness criteria' to help apply the clinical practice guidelines its' dedicated guideline committees have worked so hard to formulate.

Many have written about this (Leape, Epstein, others) but no one yet has tried to take real action. Deyo & Mirza in 2010 described a 15-fold increase in complex surgery for spinal stenosis (as occured in my Power Point example) between 2002 and 2007. 

The JC's Mission Statement extols 'Quality Care and Patient Safety' in hospitals it accredits, but it has not yet acknowledged or confronted the problem of  unnecessary or excessive surgery. When asked JC says they depend upon the hospitals QA committees to control this -- but there are no guidelines, no monitoring and no sanctions for cases such as that described in my Spinal Stenosis PowerPoint. I am preparing a presentation to The Joint Commission on this point and I may ask SIDM to weigh in. 

Phil Benton 

Atlanta, GA

-----Original Message-----
From: robert bell <rmsbell at ESEDONA.NET>
To: IMPROVEDX <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Sent: Mon, Apr 13, 2015 2:32 pm
Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error

Excellent point. 

 Where are the loyalties of the Joint Commission - are the mainly patient or hospital?  Who pays the JCs fees? I ask this as there seem to be 100s many areas where the JC could help reduce errors to a far greater extent. Accurate data collection could be a start. 

Insurance carriers often are asking for approval for expensive procedures, operations, or drugs. Do they ever challenge a surgeons decision to perform an operation?  Are second opinions ever sought in those situations?  Could the Insurance Carriers be the filter that you ask for? 

But let’s not forget ambulatory care diagnostic errors, which must be massive, when so many do not have the training to diagnose many of the conditions. 

 Rob Bell 

 

 







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