insurance companies

Personalized medicine offers hope, but not today

Anne Zieger — Tue, 06 Jan 2009 10:55:23 -0500

Right now, the pharmaceutical industry counts on a time-honored practice to keep its coffers full. As things stand, if clinical testing shows that a drug is effective for some subjects with a given condition, it's given to everyone who qualifies for it, even though only half of such patients typically benefit.

Eventually, researchers hope to study such hit-or-miss methods with the more-precise techniques of personalized medicine, in which genetic screening or other tests help doctors isolate which patients will actually benefit from a drug. However, experts note that it could be quite some time before this approach actually becomes widespread.

Among the biggest obstacles, they say, is that pharmaceutical companies fear that personalized medicine will lower their sales. Another big issue is that insurance companies are presently reluctant to pay for the tests needed, as they can cost as much as a few thousand dollars each. Not only that, right now there's no standardized way of measuring whether the genetic tests themselves are being done accurately.

All told, given these issues, it could be decades before the use of personalized medicine becomes common, researchers suggest.

To learn more about personalized medicine:
- read this Kaiser Daily Health Policy Report item

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Generics save consumers, insurers $1 billion

Anne Zieger — Mon, 15 Dec 2008 09:51:58 -0500

Apparently, the worsening economy has an upside: it drove consumer demand for generic treatments up by 5.4 percent. That, combined with the large number of generics entering the market this year and lower prices from pharmaceutical companies, created a perfect storm that drove generic spending down by 2.7 percent over the 12 months ending in September.

That decrease is the largest in the past decade, perhaps longer. And the report with these details, released by IMS Health, predicts that the trend will continue at least through 2012.

Also cited as reasons were the increased competition among manufacturers of generics, and pressure from large retailers to make treatments increasingly inexpensive. Whatever the reasons, the decrease saved consumers and insurance companies $1 billion dollars.

To learn more about the results:
- read this Kaiser Daily Health Policy Report piece

A new strategy for harried physicians: See patients in groups

Anne Zieger — Tue, 02 Dec 2008 08:46:25 -0500

There's no doubt that the world of medicine is changing, and many physicians, especially primary care physicians, are struggling. Long hours and not even enough compensation are leading many to consider cutting back on their hours or even retiring.

But at Harvard Vanguard Medical Associates and a few other offices around the country, physicians are experimenting with a new strategy that could help them reduce the number of hours worked, increase patient satisfaction, and even make reimbursements from insurance companies go a lot further.

The new strategy? Shared medical appointments. Doctors take approximately ten patients for one ninety-minute appointment. If any patients have similar ailments, the doctor doesn't have to give his explanations more than once, and patients can learn from the other patients' questions.

Harvard Vanguard did a survey, and found that 77 percent of patients said they would go to another group visit after attending a first. Most of the rest said that they might, with only five percent saying that they wanted to go back to an individual appointment.

Obviously privacy concerns have to be dealt with, and shared medical appointments require a different space to work in than traditional appointments with one doctor and one patient in a room. However, when patients are willing to give up a little privacy, they can gain a large amount of time with the doctor--and the doctor gains a lot more time to relax while still seeing his patients.

To learn more about this approach:
- check out this video
- read this Boston Globe piece

Universities receiving kickbacks from health plans?

Anne Zieger — Mon, 17 Nov 2008 10:43:51 -0500

Everyone is worried about kickbacks doctors may be receiving from insurance companies or medical device manufacturers, but that's apparently not where the payola ends. It seems New York is now concerned about kickbacks universities could be receiving from insurers.

New York state attorney general Andrew M. Cuomo has started investigating a number of state colleges and universities to determine whether there is anything untoward in the relationship between the schools and the insurance companies that cover their students.

The investigation seems to have been started by parents' complaints that their students were being forced to purchase insurance from the school as a condition of enrollment, even though they were already covered on the parent's insurance policy. Two years ago, Cuomo investigated similar links between colleges and student loan programs.

To learn more about the investigation:
- read this New York Times piece

India benefits from fertility-related medical tourism

Anne Zieger — Thu, 23 Oct 2008 09:55:09 -0400

With health plans beginning to cover medical tourism, India is finding its medical tourism business booming, especially when it comes to fertility treatments. It's little wonder, either; after all, India has little to no legislation controlling egg donation, and a full cycle of IVF at the premiere clinic costs only $4,500. Compare this to the average cost in the United States, which is $12,400. And many other clinics in India cost half as much.

Of course, there continue to be concerns over the safety of such treatments. The very reason that people are traveling all the way to India for these treatments (lack of regulation) is also a very good reason to step back and consider whether the treatment is safe. For example, doctors in India implant up to five embryos during one cycle, compared to a maximum of two in Britain. This increases the likelihood of success, but it also increases the danger to the mother.

As medical tourism grows, similar questions will continue to be asked: Is it worth the risk? Or, is this exactly what insurance companies have been trying for: less expensive alternatives to drive down the costs?

To learn more about fertility-related medical tourism:
- Read this AFP piece

Have cancer drug prices topped out?

Anne Zieger — Mon, 13 Oct 2008 14:27:47 -0400

Today, most pharmaceutical companies see oncology medications as their best hope for big future earnings, as these drugs have big pricetags and offer unique benefits. In the future, however, some companies may refuse to pay these prices, notes sister publication FiercePharma. In fact, pharmas are already beginning to slash the price of some cancer drugs, as they're well aware that insurance companies won't pay as much as $100,000 for six months of life for much longer. FiercePharma

CA finalizes bills boosting patient privacy

Anne Zieger — Thu, 02 Oct 2008 13:31:55 -0400

California governor Arnold Schwarzenegger signed a new law that imposes tougher penalties for violations of patient privacy as well as for serious medical errors. Under the terms of the bill, the state will create an Office of Health Information Integrity, whose job will be to to assess penalties against individuals who violate patient privacy. It will have the authority to impose fines of up to $250,000, no joke when you're an average individual consumer. It will also raise fines for serious medical errors by hospitals from $25,000 to as much as $125,000 per violation. The bill was drafted in response to UCLA Medical Center privacy violations in which patients spied on celebrity medical records.

At the same time, Schwarzenegger vetoed a bill that would have required insurance companies to prove that patients intentionally mislead them before the insurers could revoke coverage. On the other hand, he approved a bill banning insurance companies from revoking family coverage based on alleged misinformation on the application of a single family member.

To learn more about this legislation:
- read this Modern Healthcare article

Related Articles:
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Provena Covenant's tax exemption in jeopardy again

Anne Zieger — Thu, 28 Aug 2008 12:15:23 -0400

For years now, Provena Covenant Medical Center has battled to keep its property tax exemption, after the Illinois Department of Revenue's Brian Hamer ruled that the facility's charity care contributions weren't enough to justify a property-tax exemption. At the time, Hamer noted that Provena Covenant's charity care level was less than 1 percent of its revenue in 2002. Provena had originally lost its exemption when the Champaign County Board of Review first yanked it for what it considered to be overly aggressive attempts to collect from the poor and uninsured.

Since then, the case has worked its way through the state court system, with one group of appellate judges siding with Hamer and another siding with the hospital.

Now, in yet another twist, an Illinois state appeals court has ruled against Provena Covenant, reversing a lower court decision allowing it to keep its tax-exempt status. The court noted that almost all of the hospital's $115 million in revenue came from insurance companies, self-pay patients and other contractual sources. The hospital has the option to appeal to the Illinois Supreme Court if it wishes.

To learn more about the case:
- read this Chicago Tribune piece

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SPOTLIGHT: Providers fight self-insured plans for payments

Thu, 29 May 2008 06:59:52 -0400

Increasingly, self-insured insurance plans offered by large employers and labor unions have become a worry for employers, who say that these plans aren't paying their claims in a reasonable amount of time. While insurance companies must contend with state regulators if they're too tardy in settling claims, self-insured plans are regulated by federal ERISA rules, which give them a great deal of leeway. And the number of workers covered by self-funded plans has risen sharply in recent times from, 44 percent in 1999 to 55 percent to 2007, making this an increasingly important concern for physicians and hospitals. Article

MA physician group files suit over rankings

Thu, 22 May 2008 06:59:58 -0400

The Massachusetts Medical Society has filed suit to stop a scheme under which doctors are ranked using cost and quality metrics by health plans working with an agency overseeing health insurance plans for public employees. The MMS says that the Group Insurance Commission (GIC), which works with thousands of state and local employees, defamed doctors that it arbitrarily ranked lower, and defrauded patients who pay higher co-payments based on their doctor's ranking.

The medical society had worked with the GIC for four years to improve its methods, and concedes that the agency made some changes. However, it still ranks individual physicians "using inaccurate, unreliable, and invalid tools and data," according to Dr. Bruce Auerbach, MMS's president.

To compile its individual physician rankings, the GIC runs an analysis on a claims database drawn from six insurance companies. However, the MMS says this approach has many flaws, including that it penalizes doctors that take on complex, expensive cases. Also, the data itself may reflect, for example, full expenses for cases in which a doctor read a chart but didn't participate in care, skewing the individual's cost results dramatically.

To learn more about the dispute:
- read this article from The Boston Globe

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