AHRQ Grants for Diagnostic Error

Robert Bell rmsbell200 at YAHOO.COM
Fri Apr 17 14:58:33 UTC 2015


I thought wrongly that Dr. Prida was talking about legal insurance companies, hence my comment, but I now see he was talking about heathcare insurance companies, as is Dr. Lawrence.

It does not alter the fact that legal/litigation insurance companies are basically on our side in the desire to reduce error?

Rob

Sent from my iPad

On Apr 17, 2015, at 6:59 AM, David Lawrance <david.lawrance at gmail.com> wrote:

> Is it not an ethical principle,at least for health insurance
> cooperatives and mutuals, to return to its purchasers the maximum good
> for a given dollar?
> 
> Many of our guidelines direct us along pathways that ultimate will not
> help the majority of patients that use them (any pathway where the NNT
>> 1.)  Many guidelines are based upon studies that exclude confounding
> variables in order to provide focus. It is easy to believe that a
> particular individual does not meet the criteria that were used in
> establishing the guideline.
> 
> Which is not an argument against following clinical pathways. It is
> simply a statement that following a guideline is not necessarily
> ultimately in a patient's best interest, and therein lies a problem.
> 
> At the time of a preauthorization request, a denial always seems to
> patient and provider as ridiculous arbitrariness. The criteria for
> whether a guideline applies or not are generally fairly simple, half a
> dozen measurable factors or less.  It doesn't take a medical
> professional to make the determination. Sticking to the guideline
> hopefully provides more good on the average than not following it.
> 
> Neither patient nor provider, insurer or anyone else can know the
> ultimate outcome in the moment. The insurer is  nudging toward or away
> from a particular guideline that seems to apply, nudged away by
> patient/provider by individual circumstance for an exception. The
> patient is nudged toward following the guideline for financial
> reasons, nudged away by knowledge that of alternate pathways. How
> should such determinations be arbitrated?
> 
> Usually, there is an appeals process that involves a medical
> professional. The intent of appeal is to show that a particular
> guideline does not apply for this particular circumstance, that there
> is evidence for this particular case for an alternate pathway. But
> generally, the appeal decision-making process seems to me to me to
> rely mostly upon expert opinion not guided by evidence-based factors.
> Should the reviewer give the patient/provider the benefit of a doubt?
> 
> At this point, the process becomes completely opaque. We have no
> knowledge of how an appeals reviewer is selected or how they are
> rewarded. There is no body of evidence that we can use to weigh the
> decision-making ability. There is no independent peer review, itself a
> most problematic quality measure.
> 
> David
> 
> 
> 
> On Thu, Apr 16, 2015 at 9:01 PM, robert bell
> <0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:
>> 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
>>> 
>>> 
>>> 
>>> On Apr 13, 2015, at 10:32 AM, pgbentonmd at aol.com wrote:
>>> 
>>> 
>>> 
>>> Rob, Mark and SIDM,
>>> 
>>> 
>>> 
>>> I would like to add another very important area in which "diagnostic"
>>> errors may cause massive and irreparable patient harm. I'm talking about not
>>> an error of diagnosis, but about the misapplication of surgical treatment
>>> indications for some diagnoses.. Currently there are no barriers to posting
>>> surgery that is inappropriate (viz unnecessary or excessive) for the
>>> underlying diagnosis.
>>> 
>>> 
>>> 
>>> Patients usually have given their "informed" consent to the procedure
>>> because they trusted their physician. Most physicians are trustworthy, but
>>> some surgeons looking to enhance the surgical fee treat surgically all
>>> pathology seen on the diagnostic imaging, or do the surgery prematurely.
>>> Attached, anonymized, is one example.
>>> 
>>> 
>>> 
>>> What we really need is a diagnosis related "appropriateness criteria"
>>> screening system at the surgery scheduling desk that the OR nurses can
>>> understand and apply, that can trigger review of questionable case postings
>>> by senior surgeons with departmental administrative responsibility for
>>> quality of care. The Department Chair will also need timely backup
>>> consultation available from specialty society Practice Guidelines Committees
>>> when needed.
>>> 
>>> 
>>> 
>>> Hopefully Joint Commission will face the problem and  join this effort to
>>> ensure patient safety and quality care in America's accredited hospitals.
>>> 
>>> 
>>> 
>>> Phillip G. Benton, MD, JD
>>> 
>>> Atlanta, Georgia
>>> 
>>> 
>>> 
>>> -----Original Message-----
>>> From: robert bell < rmsbell at ESEDONA.NET>
>>> To: IMPROVEDX < IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>> Sent: Mon, Apr 13, 2015 11:33 am
>>> Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error
>>> 
>>> That was the point I was trying to make previously, and asking where most
>>> diagnostic errors are to be found.  In hospitals or in private specialty
>>> practice and primary care practice?
>>> 
>>> 
>>> 
>>> If it is thought that most diagnostic errors come from the latter, then
>>> funding should be be available there.
>>> 
>>> 
>>> 
>>> Rob Bell
>>> 
>>> On Apr 12, 2015, at 4:24 PM, Julianne Nemes Walsh < nemeswalsh at GMAIL.COM>
>>> wrote:
>>> 
>>> 
>>> 
>>> After reviewing the grant criteria, primary care practice groups that are
>>> not attached to a higher ed institution are not eligible.   Would love to
>>> see grant opportunities available to smaller settings to stimulate more
>>> diversified opportunities for all levels of providers interested in
>>> diagnostic error.
>>> 
>>> 
>>> 
>>> On Thu, Apr 9, 2015 at 9:52 PM, <graber.mark at gmail.com> wrote:
>>> 
>>> This is a big day for our diagnostic safety community:  AHRQ has just
>>> issued the first-ever grant announcement that specifically targets “
>>> Diagnostic Safety in Ambulatory Care”.  Both R01 (large grants) and R18
>>> (small grants) will be funded under this initiative, which will be open
>>> annually until 2018.  With so many proposed, but untested interventions that
>>> have been raised, there’s many opportunities.  Go get ‘em !
>>> 
>>> 
>>> 
>>> Mark
>>> 
>>> 
>>> 
>>> Mark L Graber MD FACP
>>> 
>>> President, SIDM
>>> 
>>> 
>>> 
>>> Title:     Understanding and Improving Diagnostic Safety in Ambulatory
>>> Care: Strategies and Interventions
>>> 
>>> Deadline Date:  Standard due dates apply: January 25, May 25, and
>>> September 25.
>>> 
>>> For details, click on the link below:
>>> 
>>> http://www.egrants.net/Public/index.cfm?ID=17660&UserID=graber%2Emark%40gmail%2Ecom
>>> 
>>> 
>>> 
>>> or copy the above link into your web browser and hit the enter key.
>>> 
>>> 
>>> 
>>> 
>>> 
>>> ________________________________
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>>> 
>>> 
>>> 
>>> 
>>> ________________________________
>>> 
>>> 
>>> 
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>>> 
>>> 
>>> 
>>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
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>>> 
>>> To learn more about SIDM visit:
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>>> 
>>> 
>>> 
>>> 
>>> 
>>> Robert M. Bell, M.D., Ph.C.
>>> 
>>> P.O. Box 3668
>>> 
>>> West Sedona, AZ  86340-3668
>>> 
>>> USA
>>> 
>>> Tel: Fax: 928 203-4517
>>> 
>>> 
>>> 
>>> I am changing my e-mail address to  rmsbell200 at yahoo.com
>>> 
>>> 
>>> 
>>> Kindly change the e-sedona e-mail above in your address book so  we stay
>>> in touch.
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> ________________________________
>>> 
>>> 
>>> 
>>> To unsubscribe from IMPROVEDX: click the following link:
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>>> 
>>> 
>>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>>> Medicine
>>> 
>>> To learn more about SIDM visit:
>>> http://www.improvediagnosis.org/
>>> 
>>> <Spinal_Stenosis.ppt_BASIC +.pptx>
>>> 
>>> 
>>> 
>>> Robert M. Bell, M.D., Ph.C.
>>> 
>>> P.O. Box 3668
>>> 
>>> West Sedona, AZ  86340-3668
>>> 
>>> USA
>>> 
>>> Tel: Fax: 928 203-4517
>>> 
>>> 
>>> 
>>> I am changing my e-mail address to  rmsbell200 at yahoo.com
>>> 
>>> 
>>> 
>>> Kindly change the e-sedona e-mail above in your address book so  we stay
>>> in touch.
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> ________________________________
>>> 
>>> 
>>> 
>>> To unsubscribe from IMPROVEDX: click the following link:
>>> 
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>>> 
>>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>> 
>>> 
>>> 
>>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>>> Medicine
>>> 
>>> To learn more about SIDM visit:
>>> http://www.improvediagnosis.org/
>>> 
>>> 
>>> 
>>> ________________________________
>>> 
>>> 
>>> 
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>>> 
>>> 
>>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>>> Medicine
>>> 
>>> To learn more about SIDM visit:
>>> http://www.improvediagnosis.org/
>>> 
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>> 
>> 
>> 
>> 
>> --
>> Xavier E. Prida MD FACC FSCAI
>> Assistant Professor of Medicine
>> USF Morsani College of Medicine
>> Department of Cardiovascular Sciences
>> Tampa, Fl
>> 
>> 
>> ________________________________
>> 
>> 
>> To unsubscribe from IMPROVEDX: click the following link:
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>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>> 
>> 
>> 
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>> 
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>> 
>> 
>> As of 1.1.2015 my new email address is: rmsbell200 at yahoo.com
>> 
>> Please update your address books accordingly
>> 
>> 
>> ________________________________
>> 
>> 
>> To unsubscribe from IMPROVEDX: click the following link:
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>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>> 
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>> 
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine




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