Dr. Skip's Medical Peer Review Blog

Antibiotics for Treating Lyme Disease

2008-11-12T13:42:00.000-08:00

How long should a patient stay on a medication? According to a study released last July, extending antibiotic treatment past the time it takes to cure Lyme disease doesn�??t do any real good.

What�??s more is that these antibiotics could be harming the patient, prolonging post-Lyme disease symptoms like fatigue, mood problems, and muscle and bone pain.

A New York Times article surveys this problem, which was initially brought up by the Journal of Neurology.

So how do you know how long to keep a patient on a medication? Using an independent review organization can help payers make the decision for use and prescription of antibiotics.

Read the full article here: http://www.nytimes.com/2007/05/29/health/29prog.html

While the U.S. Spends Heavily on Health Care, a Study Faults the Quality

2008-07-17T12:57:00.001-07:00

Usually paying a premium for services and goods means you�??re getting a product of higher quality in return. For example, organic produce costs more than conventionally-grown produce and octane 92 gas costs more than octane 89 but you get what you pay for: better fruits and cleaner gasoline.

According to a study conducted by Commonwealth Fund, a nonprofit research group in New York, this get-what-you-pay-for formula is not the case for the American healthcare system. The report shows that the United States spends more than twice as much on each person for health care as most other industrialized countries but has fallen to last place among those countries in preventing deaths through use of timely and effective medical care.

In summary: Americans are paying way too much for very little. The study also examines costs and inefficiencies within the American healthcare system. The administrative costs of the medical insurance systems consume much more of the current healthcare dollar, about 7.5 percent, than in other countries.

One avenue that healthcare payors can take to reduce costs is to outsource review cases to independent review organizations (IRO). IROs are efficient, cost-effective and knowledgeable, providing peer specialists who are actively practicing and up-to-date with today�??s medical standards. By ensuring that reviews are done according to current medical standards, IROs reduce extraneous administrative costs of rework and re-reviewing.

Read the full article.

Aggressive New Recommendation for Warding Off Heart Disease in Some Children

2008-07-11T14:09:00.001-07:00

By now, most people in the medical profession are aware of the American Academy of Pediatric�??s recommendation for wider cholesterol screening for children and more aggressive use of cholesterol-lowering drugs for kids, starting as early as age eight. The controversy of the recommendation stems from the fact that the AAP�??s statement comes from mere speculation of how statins work in adults. According to an article in The New York Times, AAP�??s doctors believe that statins will function the same in children as they do in adults, a speculation that is absent of any evidence-based medicine and clear data.

The importance of evidence-based medicine is clear in this controversial mishap. Just two days after issuing the recommendation, AAP retracted the statement, offering apologies for unclear thinking and lack of evidence-based medicine. Relying on evidence-based medicine is a sure-fire way to make the best decisions for a treatment. An independent review organization bases its decisions and recommendations on evidence-based medicine in order to determine medical necessity and increase patient safety.
Read the initial article about the American Academy of Pediatric�??s recommendation

The Evidence Gap: Weight the Costs of a CT Scan's Looks Inside the Heart

2008-07-02T11:23:00.001-07:00

The latest feature of The New York Times series, The Evidence Gap, delves into controversial issue of emerging and cutting edge technologies in healthcare. The article, �??Weighing the Costs of a CT Scan�??s Look Inside the heart,�?? offers the pros and cons of a new cardiology medical device. The CT Scan can provide cardiologists with a new way of looking into patients�?? arteries, a boasting reputation of offering cutting edge technology as well as extra revenue. On the other hand, the new CT Scan exposes patients to large doses of radiation. It is costly machine�??$1 million�??and an expensive procedure that has yet to yield better results.

According to The New York Times, this new CT Scan controversy showcases the American healthcare system as: �??faith in innovation, often driven by financial incentives [which] encourages American doctors and hospitals to adopt new technologies even without proof that they work better than older techniques.�?? The CT Scan is just one of many costly procedures that leads to hundreds of billions of superfluously spent dollars, with no justification.

An independent review organization (IRO) is helpful in a situation like this because they back their decisions with evidence-based medicine. Furthermore, they weigh the benefits of a procedure�??detecting heart disease�??against its risks�??high radiation exposure levels. All in all, an IRO can decide whether its medically necessary for a patient to receive a particular treatment, elimating unnecessary procedures, reducing the nation�??s superfluous spending on healthcare, while making sure patient safety is the top priority.

Read the full article

With a Tiny Bit of Cancer, Debate on How to Proceed

2008-06-04T08:45:00.000-07:00

The New York Times reported that oncologists are able to catch more lymph node abnormalities than ever thanks to sophisticated and sensitive lymph node biopsies. What seems like a medical advantage�??the ability to catch even the slightest hint of cancer�??is actually causing more problems for oncologists who are unsure of what to do with the micrometastastic diagnoses they are making.

Currently no standards of care exist for the diagnosis of micrometastases�??wisps of tumors too small to be considered full-fledged metastases. This means that oncologists are navigating through murky waters filled with an abundance of treatment decisions and options while worrying whether a treatment of these minute clusters of cancerous cells will benefit the patient in the long term.

Independent Review Organizations come into the equation here. With the combination of emerging standards of care and ever-advancing screenings, diagnoses and treatments, making the correct and informed decision to best benefit a patient is especially important, requiring demanding research and thorough knowledge. An IRO offers the knowledge of a specialist to help payers make the best decision for patient care.

Read the full article

5 percent of Mass. taxpayers uninsured, some fined

2008-06-03T06:46:00.000-07:00

This article shows how Massachusetts is making progress in enforcing its new law regarding universal healthcare coverage for all of its residents. We're in favor of it. In order to lower costs and improve health care quality in this country, it's essential that we get everyone into the risk pool. Massachusetts is leading the way in this area, hopefully paving the way for a similar initiative at the national level once a new president is elected. As an independent review organization that is deeply involved in allocating health care resources in the US, we feel that a universal coverage mandate will help drive costs down and is a key step toward healthcare system transformation.

By STEVE LeBLANC, Associated Press Writer

BOSTON - Nearly 100,000 Massachusetts taxpayers have been fined for failing to obtain health insurance, even as a major survey concludes the effort to create near-universal coverage in the state is meeting key goals.

Five percent of taxpayers failed to obtain health coverage last year, and more than half of those �?? about 97,000 �?? were forced to forfeit their personal exemption �?? worth $219 �?? after it was determined they could have afforded health care.

Two percent of taxpayers �?? about 62,000 �?? were found not to earn enough for health care, avoiding fines. Under the landmark law, taxpayers must show they are insured or face penalties. The numbers were based on a review of 86 percent of expected tax filers for 2007.

The state's first-in-the-nation universal health insurance law required everyone in the state to be insured by July 2007, except for those who secured a waiver proving they couldn't afford insurance.

Read the whole article

Utilization Review & The Role of Independent Review Organizations

2008-05-13T07:53:00.000-07:00

This article points to the critical role that utilization review plays in effective medical management, and the increased exposure that organizations face if they don't review the medical necessity of advanced patient treatments and hospital stays . With constantly changing care standards, the need to protect the integrity of patient care while limiting the impact of increasing costs, UR professionals play a pivotal role in today's health care delivery system.

UR organizations are only as good as the medical specialists who review their more advanced cases. For this reason, most medical management firms and UR organizations tap into the peer specialist capabilities of an independent review organization (IRO), which provides them with pre-authorization of their most complex and difficult claims. Since UR organizations can't afford to build/maintain a panel of these specialists, IROs represent a cost effective alternative which allows them to ensure that all complex claims determinations are made by board certified specialists who are in active practice. We provide these services to hundreds of UR and case management professionals in leading health care payor organizations across the US.

May 12, 2008

Strong Utilization Review Committees Can Prevent Inappropriate Hospital Admissions

Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues.

By Nina Youngtrom, Managing Editor, (nyoungstrom@aispub.com)

With all the pressure they face to reduce medically unnecessary admissions, hospitals need strong utilization review (UR) committees �?? especially since there have been few consequences for physicians whose admission decisions conflict with strict Medicare regulation and guidance (though that is starting to change).

An effective UR process, powered by highly trained case managers and physician advisers, is a great way to help prevent inappropriate inpatient admissions, according to Atlanta attorney Mitch Mitchelson, who represented the first hospital to settle a false claims lawsuit for alleged medically unnecessary inpatient admissions, and physician Robert Corrato, M.D., CEO of Executive Health Resources in Newtown Square, Pa., who served as a medical-necessity expert in the case.

Increased Scrutiny on Admission Necessity

Admission necessity has probably never faced more oversight - from recovery audit contractors, Medicare quality improvement organizations and program safeguard contractors (which are morphing into zone program integrity contractors). With advances in medicine and technology, more procedures can be performed on an outpatient basis, putting pressure on hospitals to establish inpatient medical necessity.

Read Entire Article

New Drug Treatments Drive Increased Utilization Review

2008-04-14T08:37:00.000-07:00

This article highlights an initiative to create an evidence-based approach to evaluating the myriad of new medical devices and drugs that are hitting the market, and which are difficult for health care payers to track and evaluate for coverage. This makes good sense. With the exponential growth in new drug therapies, it's getting harder for payers to stay on top of what should be covered and what should not at the macro level. This is particularly important in light of the cost of many new drug regimens, and the need to control over-utilization. At the micro level, it means that more payers (including PBMs) are seeking outside help from IROs in order to make medically necessity determinations, develop drug formularies, and to handle member appeals when specific drugs or devices are denied.

FDA news Drug Daily Bulletin April 14, 2008 | Vol. 5 No. 73

Comparative-Effectiveness Bill to Hit Senate

A bill establishing a comparative-effectiveness research institute is scheduled for introduction in the Senate this week, congressional staffers say.

The Comparative Effectiveness Research Act of 2008, sponsored by Sens. Kent Conrad (D-N.D.) and Max Baucus (D-Mont.), would establish an institute to evaluate the effectiveness of different drugs and medical devices that exist for the same treatment.

The creation of such an organization was the subject of a public meeting held last week by the Medicare Payment Advisory Commission (MedPAC), an independent agency that advises Congress on issues affecting Medicare. The group supports a comparative-effectiveness program and recommends that Congress establish an independent entity to sponsor and disseminate such information. The entity would conduct prospective, head-to-head clinical trials of competing products as well as clinical reviews.

Read The Full Article

Medication Mismanagement On The Rise

2008-03-11T08:31:00.000-07:00

This article points to one of the growing impacts of the cost and complexity of drug treatments, another indicator of how U.S. health care is in serious need of a makeover. The complexity of drug offerings is staggering, with hundreds of new pharmaceuticals hitting the market each year, and hundreds more in the pipeline. In addition, the cost of these treatments is directly driving double digit increases in health care costs. Pharmacy Benefit Management companies (PBMs) and drug utilization review firms are growing at a rapid pace, trying to manage the allocation of benefits and help health insurance payers to reduce the increases in costs. As the complexity of drug interactions skyrockets, Independent review organizations (IROs) are playing an increasing role in reviewing the medical necessity of drug utilization, by using specialists to provide medical peer review of drug benefits.

More prescriptions, greater confusion

Medications improve the lives of seniors, but errors in taking them can be lethal

Excerpts from an article by Tanika White, The Baltimore Sun

March 9, 2008

"Medication mismanagement among seniors is a growing problem in the United States. Some experts estimate that half of all seniors mismanage one or more of their medications, and seniors are twice as likely to end up in emergency rooms because of drug safety issues.

As the baby boom generation ages - and older Americans take more medications to deal with chronic illnesses - medical professionals have become increasingly concerned about the issue.

"Not only is it getting worse, it has become one of the major sources of hospitalizations in the country and one of the greatest preventable causes of illnesses - and costs associated with illnesses - in this country," said George Lowe, director of medical services at the Overlea Physicians medical clinic in Northeast Baltimore. About 60 percent of his patients are seniors."

Read the entire article: http://www.baltimoresun.com/news/health/bal-te.md.meds09mar09,0,85144.story

Accountability + Transparency = Improved Quality + Patient Safety

2008-02-22T08:49:00.000-08:00

Building & Leading a Continuous Improvement Culture

As I roam the internet looking for new knowledge and ideas on how to improve External Peer Review,I'm amazed at the plethora of statistics, data, measures and analysis that's being done in the name of improving hospital quality and patient safety. My hat goes off to those who use analytical tools as the foundation for performance improvement in hosptials.

Having said that, in my humble opinion, we could make much great strides in much shorter time if management and medical staff focused more of its effort on building accountability and transparency into their hospital cultures, as opposed to spending more time and money crunching numbers.

An increased emphasis on setting clearer practitioner expectations, measuring and monitoring their performance, sharing performance data and holding poor performers accountable is what's in order. We see/hear of too many situations in hospitals across the country where conflict of interest, conflict avoidance, cover-ups and other behavioral dysfunction allow under-performing physicians to keep doing what they are doing.

What I'm advocating is medical staff leadership that goes beyond analysis and statistics, but rather uses this data to place increased emphasis on creating a culture of continuous improvement. In such a culture, sentinel event data is openly shared, performance is actively measured, practitioner work is subjected to regular/period external peer review, and poor performers are put on a corrective action program, no matter who/how important they are.

Making UR & Claims Determinations Easier for Healthcare Payers

2008-02-06T14:52:00.000-08:00

If you're a utilization review or claims professional dealing with acute or chronic care populations, you probably deal with lots of cases that fall outside your normal criteria or plan language, and into the "gray zone." As you know, the standards of care are rapidly changing with emerging medical treatments, new technologies , drugs, etc. As a managed care professional, it's impossible to stay up on all of the latest changes in care management. What to do?

We've created a publication called "The Cutting Edge," which is designed to help critical and complex claims professionals stay on top of changing standards of care. Each issue features articles written by top specialists who are experts in their respective fields, who are board certified and in active practice. In these articles, you'll find information that will help you make more informed retrospective and pre-certifications decisions, based on the latest medical evidence.

Interested in signing up to receive a free copy? Click here: http://www.allmedmd.com/peerpoints/cuttingedge/cutting_edge_form.htm

-AGR

External Peer Review Solves Hospital Performance Reporting Issues

2008-02-06T10:21:00.000-08:00

Most Doctors Do Not Report Incompetent Colleagues, Survey

Written by: Catharine Paddock
http://www.medicalnewstoday.com/articles/90676.php

This article summarizes a recent national survey of physicians that indicates a serious discrepancy between the number of doctors who believe they should report incompetence (96%) and the number that actually do (45%). Conflict of interest is the key issue here, where physicians are either friends or economic foes. This study strongly supports the need for independent mechanisms that ensure evidence-based measurement of physician performance on a systematic and ongoing basis. Internal peer review committees often fail to address these types of issues. External medical peer review can go a long way toward helping to close this gap, while ensuring that poor performance is identified and dealt with in a fair and consistent way.

Survey:
"Professionalism in Medicine: Results of a National Survey of Physicians."
E. G. Campbell, S. Regan, R. L. Gruen, T. G. Ferris, S. R. Rao, P. D. Cleary and D. Blumenthal.
Ann Intern Med 2007; 795-802.
4 December 2007, Volume 147 Issue 11, Pages 795-802.

Medical Collaboration and Cancer Networking

2008-01-29T16:56:00.000-08:00

Last week cancer researchers announced plans to create a giant database designed to allow oncologists and scientists to share vital information. Rutgers University, the Cancer Institute of New Jersey (CINJ) and IBM are building a computer system allowing doctors and researchers around the globe to tap into the most current developments in cancer treatment and research. The researchers see it as a tool to help doctors tailor the best possible treatments for patients. It also gives researchers the ability to follow the successes and shortcomings of earlier research.

The full story is in Scientific American.

The Right Vision of Health Care?

2008-01-09T17:36:00.000-08:00

Yaron Brook, managing director of BH Equity Research and executive director of the Ayn Rand Institute, has a op-ed this week in Forbes by the above title. He brings up several interesting questions and skewers both political parties approaches to health care reform.

But while lambasting the consumer for putting the healthcare burden on government and not paying their fair share, he forgets to mention that healthcare costs have risen to a point where many people cannot afford the healh insurance, let alone the cost of care.

If you're making some decisions about either parties or candidates to vote for, this one is worth a read.

The Right Vision of Health Care

IROs Improve Healthcare

2007-11-28T16:03:00.000-08:00

The presidential elections are soon to be upon us, and it's time to start digging deep to find out where each candidate really stands on health care reform. This is no easy task -- most of them hide behind political rhetoric and make it very hard to understand what they will do specifically to address the healthcare crisis, if elected.

No matter what happens in Washington, one thing's certain: Independent Review Organizations will play a critical role in reducing cost and improving the quality of health care as we move forward. We'll explore this topic in detail over the weeks and months to come...

Hospital Peer Review = An Ounce of Prevention....

2007-04-13T15:45:00.000-07:00

The old adage about an ounce of prevention is equal to a pound of cure is certainly the case when it comes to sending out suspect issues that have a potential for malpractice or liability litigation in the hospital environment. Why is this? Because while nobody wants to spend their resources defending themselves, the faster you can get to clarity on the root cause of a particular sentinel event in your hospital, the faster you can determine what the appropriate measures to take are in order to protect your hospital from litigation.

Those protective measures could include settling the case early through an offer to a potentially interested party to a lawsuit. It could also include sanctions against physicians or other staff who have behaved improperly, or taking a tougher stance in pre-litigation negotiations when you know that nothing was done wrong and that it can be proven in court that all procedures were followed and the physicians performance which is in question was correct.

Outsourcing cases to an external peer review organization or to an independent review organization can help your company to quickly get to clarity on what the best course of action is as it relates to defending your hospital; sanctioning, taking corrective action inside with your staff, or settling. If you're a risk management professional and you haven't adopted peer review as part of your best practices for your quality management systems, talk to your colleagues, go to industry conferences, and listen to how external peer review is rapidly being adopted or is the best kept secret and best practice of many leading hospitals and hospital groups across the country.

How to Reduce Liability Insurance Exposure

2007-03-30T15:25:00.000-07:00

We talk to hundreds of hospitals across the country every week. In our dealings with them we've come to realize that liability insurance carriers who are protecting hospitals are increasingly either requiring or strongly recommending that their risk management professionals insist upon sending all sentinel events out for external peer review. Why? Well, the fact is that hospital peer review is rapidly becoming a best practice for insuring quick case resolution, root cause analysis of sentinel events, and illuminating conflicts of interest when it comes to insuring quality and patient safety.

It's no secret that all insurance companies expend a certain percentage of their revenues on helping their clients to improve their practices in order to reduce costs when it comes to risk management. Professional liability insurers who operate in the hospital group space are using peer review as another strategy to help their clients lower their experience ratio and improve the root cause analysis that leads to a reduction in sentinel events.

The external medical peer review process when integrated into a hospital quality management system provides an outstanding remedy to the professional liability insurance premium escalations that have now turned into a crisis in so many states across America. If you're a CEO or hospital administrator looking for ways to reduce your risk and reduce your liability premiums so that you can reduce the costs of providing services to your patients and your local population, consider an investment in an external review process every time you have a sentinel event that has a potential for litigation. By sending cases out for external peer review, you can often prevent any potential lawsuit by insuring that nothing was done wrong by your medical professionals and hospital staff that lead to a particular sentinel event.

Managing Professional Liability Costs Through Peer Review

2007-03-29T11:08:00.000-07:00

If your hospital is like many across the nation, you're facing a crisis in being able to manage your professional liability costs in the face of rising lawsuits and rapidly increasing premiums. What's the root cause of this problem? Well obviously it's lawsuits coming from patients who have experienced sentinel events or negative outcomes such as deaths, hospital readmissions, etc. While these patients and their families are entitled to relief in certain circumstances when medical treatments go bad, the fact is that most hospital administrators are being crushed by the rise in liability costs.

If you are a hospital administrator or CEO and looking for remedies in this regard there are a number of things that you can be doing. First and foremost is taking a holistic look at your quality of care delivery system and in particular, look at your quality management system. Taking an outside assessment of your quality management system can provide insight to where your potential root causes are that are leading to sentinel events and in turn produce the kind of litigation and lawsuits that drive insurance premiums up.

These premiums don't get driven up only by actions in your own hospital but by actions across the board in all hospitals. In our litigious society today it's no secret that when people feel that a service provider (particularly in the medical environment) has wronged them, their first impulse is to find a litigious, fee hungry attorney who is willing to take on a malpractice suit or a suit against the hospital on contingency. Since it doesn't cost them anything to sue, it's very easy for them to get started.

Who bares the brunt on these costs? In general, ultimately consumers do as well as health plans, hospital providers - everybody suffers under an overly litigious system which rewards people for bringing suits against others. If you are a hospital in today's environment there is no question that liability insurance premiums are on the rise and are going to continue to escalate. The exception is those hospitals that can demonstrate the absolute best practices when it comes to quality management.

How To Select the Best Independent Review Organization

2007-03-15T11:51:00.000-07:00

If your company is in the process of looking to hire its first independent review organization, many of the topics that were just listed in this blog can provide you with the criteria that you should be using as you go through your selection process. Certainly URAC accreditation is another important one.

Our suggestion is: If you're going to hire an IRO, look beyond just the surface of a company's size. Look at what their critical attributes are. What sort of commitment does it have to customer service? What are its quality management systems and measurements? What sort of reporting can it provide to you? How quick are the turnaround times? Do they exceed the URAC turnaround times? What sort of culture does the IRO have inside its company relating to continuous improvement, quality management, and training. These are some of the criteria that I would apply if I were out looking for a new IRO to add to my vendor list. I would suggest that if you're interested in talking more about that, you consult with some of your other colleagues to find out what company they're using and who they hear is among the best.

Importance Of Having A On Site Clinical Staff in Independent Review Organizations

2007-03-08T18:11:00.000-08:00

Many independent review organizations actually work without having any onsite clinical staff within their companies. In fact, they have administrative and operational people who provide the coordination of sending, receiving, proofing, and editing reviews that are done only by outside specialists.

Our own viewpoint is that an IRO today needs to have an internal full time clinical staff working inside the company. There are a number of reasons for this. First, having doctors on staff allows us to provide a much higher level of customer service to our clients than IROs who don't. Second of all, those doctors are needed in order to correctly select the right specialists for each review that comes in. Why is this? Many of these review requests are highly technically and only can be decided upon in terms of where to send cases by a physician. Third, having in house physician staff allows us to interpret and communicate with specialists who are on our peer panel at a much higher level than IROs who do not. Finally, many of our clients ask for us to make telephone calls to attending physicians prior to rendering a final review determination. This is next to impossible to organize between a peer specialist who is in active practice and an attending physician. Therefore, it makes sense for us to have our own medical staff that is capable of doing this in house. Typically, multiple attempts have to be made in order to catch an attending physician when they're not seeing patients. Having your own medical staff is the way you achieve this.

For a number of reasons today's IRO is called upon to have a full time clinical staff to be able to interface at the level that is required in order to meet customer demands. Our own clinical staff consists of primary care and emergency physicians. In addition, they are supplemented with physicians assistants and registered nurses who work for them but can still use their medical knowledge to interpret cases and provide some of the background work required as a part of the independent review process.

Independent Review Organizations and Credentialing of Specialists

2007-03-01T13:51:00.000-08:00

We run across clients who are shifting over to us when their previous Independent Review Organization has amounted to nothing more than a doctor with a small group of his or her buddies who are reviewing charts and providing medical determinations to their clients. That doesn't cut it in today's day and age. An IRO has to have a core competency in recruiting and credentialing top specialists from each specialty area and subspecialty area, as well as allied healthcare fields in order to be at the top of its game.

Our organization has recruited and credentialed well over 300 specialists across the country. AllMed Healthcare is actually one of the smallest. Some IROs have as many as 3 or 4 thousand reviewers. We don't believe that this is effective because unless you're managing huge volumes of independent reviews every day it pays to have fewer specialists doing more reviews so that they can maintain a level of training and involvement with your company. When you over recruit specialists what happens is they never get reviews from you and as a result, they can never remember what the elements of the review processes are and ultimately this leads to a higher level of turnover amongst the specialists.

An IRO needs to be able to recruit and attract the top specialists from their field and this is no trivial task. Neurosurgeons, oncologists, and radiologists (just to name a few), these are doctors who are very highly compensated and extremely busy. Typically, it's very difficult to attract these types of specialists to your company and retain them. An IRO has to be able to exercise both science and art in the process of attracting, retaining, training, and developing these capabilities as a part of it's infrastructure. Recruiting and retaining top specialists is no trivial task for an IRO, and one that adds a lot of value to the process of providing medical reviews for our clients.

Independent Medical Review and Customized Reporting

2007-02-14T10:42:00.001-08:00

Many of our clients call upon us to provide them with customized reports at the end of each month which outline a number of different elements of the reviews that we've performed for them. From simple reports that list the clients, dates, patient names, and the outcomes through to more advanced reports that relate to reliability, returns on investments, and other elements.

An IRO needs to have advanced database management capabilities which allow them to prepare and customize reports of these natures in order to furnish them to clients on a timely basis. Clients want the IRO to be able to abstract this information and provide it to them for analysis, as opposed to asking the client to take on this burden. As medical management firms, TPAs, and health insurance plans look to outsource more of their medical decision making processes to IROs, it stands to reason that they want to outsource a lot of the analytics and reporting that would go with it. Today's IRO needs to be able to respond with advanced capabilities when it comes to database management, reporting, graphical analysis of data, and interpretation.
medical management
independent medical review

Independent Medical Review and Emerging Standards of Care

2007-02-14T10:10:00.000-08:00

It's no secret that we're dealing with an always changing playing field with emerging medical treatments and what is accepted as being a standard of care. Indeed right now we see a shift going on as it relates to the medical necessity of beriatric surgery which, as everyone knows, is a quite complex and very costly treatment procedure for obesity. A few years ago this procedure was being denied systematically by most health plans, and today it's coming into the mainstream of treatment and being more consistently embraced by health plans as a remedial measure for treating patients who have tried but failed at diet and exercise.

An Independent Review Organization needs to stay abreast of these changes as they are happening and adapt its decision making criteria and processes in order to make sure that the decisions rendered on independent medical reviews meet those changing standards of care for medical necessity. Treatments that were once experimental or investigational are moving in the direction of being medically necessary as well. In areas such as cancer treatments we see a number of new types of medicines coming out and being moved through the FDA approval process and then into the mainstream of cancer treatments. An IRO needs to have specialist as well as tracking systems, databases, and information libraries which allow it to continuously evolve its decision making criteria to what is medically necessary in accordance with movements in modern medical thinking.

healthcare
medical management
independent medical review

Independent Review Organizations and IT Systems

2007-02-07T09:57:00.000-08:00

Gone are the days when you can just have Microsoft Word and a couple of other applications at your company and be capable of dealing with the administrative and quality workflow that is required in order to be an IRO. Today, best in class IROs are investing in integrated web applications that provide an automated workflow between clients, their own operations, and peer specialists. In fact, AllMed Healthcare Management is in the process of rolling out it's own application called PeerPoint, which will greatly streamline and improve our ability to automate the workflow.

Companies that want to be in the business of providing independent medical reviews have to have a high degree of integration of their IT systems in order to be competitive. That includes having standardized operating systems at the network level and at the application level building customizing software applications that integrate and provide for administrative efficiency when it comes to taking in, assigning, processing, and returning independent medical reviews to its clients.

An IRO needs to have a quality IT process, standardization of operating systems, privacy and security procedures as it relates to IT information systems. These are all the kinds of things that the IRO has to maintain from an IT standpoint in today's environment.
healthcare
medical management

Independent Review and State Regulations.

2007-01-26T15:15:00.000-08:00

Independent review organizations are primarily regulated at the state level. The myriad of regulations makes it a very complex task for an IRO to track. State regulations in turn can be quite difficult to interpret and require an advanced understanding and ability to interpret legal jargon and long, complicated, government documents. The IRO must have an ability to manage, maintain, and anticipate any changes going on at the state level that could change the way in which it must operate. Our view is that these state regulations are very encumbering and we would like to push for a unification of healthcare regulations at the national level that would greatly ease the administrative burden on organizations that are doing business across multiple states. In particular, an IRO like ours which is doing business in more than 30 states needs to maintain a heavy administrative overhead just to track and manage the changes that relate to state regulatory bodies.

We believe that this kind of tracking and management is really wasteful and if a set of national standards would emerge it would make it much easier for us to adhere to one set of standards as opposed to having to manage multiple ones. In any case, the modern IRO must be capable to adhering to all of these standards. It's part of the reason why being an IRO is not a trivial task.

healthcare
medical management
state regulations