Insurance industry and DxError reduction: partnership opportunities

Vic Nicholls nichollsvi2 at GMAIL.COM
Fri Apr 17 13:35:49 UTC 2015


The NPSF has no patients (maybe 1) on their board. Since we are the ones 
that the system is supposedly for, why isn't there a lot of inclusion of 
patients with a huge voice in that group?

I sent a number of questions to them about the organization, etc. and 
got no response back. How can the system improve when a bunch of 
businessmen who don't get the same service or the like as the regular 
John Doe patient are the ones putting it together?

Some of us actually contribute. I've got one local system that after 
harm was suffered, changed things but dropped my care. I've seen 
retaliation behaviors. Since when is that condusive to a relationship to 
making things better and improving diagnosis?

Victoria


On 4/17/2015 9:29 AM, Lorri Zipperer wrote:
>
> 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 <mailto: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 <mailto: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
>     <mailto:0000000697ec7b18-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>]
>     *Sent:* Monday, April 13, 2015 3:23 PM
>     *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>     <mailto: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 <mailto:rmsbell at ESEDONA.NET>>
>     To: IMPROVEDX <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>     <mailto: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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