Health Care Reform Title I Reimbursement Structure Part 2

We are looking at part of the new health care reform law which is in 9 main parts. We have been looking and will continue to look at Title I – Quality Affordable Health Care for All Americans. I previously discussed insurance market reforms which I think are very positive and will increase availability and continuity of coverage. Yesterday I talked a some about the interesting requirement for insurance companies to report to the Department of Health and Human Services changes they will make in reimbursement structures to make it more likely that certain outcomes will be achieved. I discussed the hospital readmission issue yesterday and will talk about the patient safety component of the required report today.

The requirement is for insurance companies to “implement activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technologies under the plan or coverage”.
Now these are all good things. What could there possibly be for me to have some concerns about this? Again the insurance companies are not required to make this happen. They are to report on how they will change the reimbursement structures. What that likely means in practice is one size fits all strict clinical practice guidelines that may in many cases be premature. For example there are three different guidelines for the treatment of bipolar disorder. There are the Expert Consensus Guidelines, the American Psychiatric Society Guidelines, and the Texas Medication Algorithm Project. All of them are somewhat different. I am concerned about a reimbursement structure for example that tells me that I must prescribe lithium for a patient before trying other treatment options. That may or may not be clinically indicated in any particular case.
At the present time we already see some of this in the insurance companies saying they will not reimburse a patient for using a certain antidepressant without trying their preferred antidepressant first even if is not appropriate. Antidepressants are not necessarily interchangeable. At the moment there is the ability for me to override the insurance companies denial. I don’t want to be in a situation where I can’t override the companies requirement.
I am all in favor of developing best clinical practice guidelines, using evidence based medicine, and making better use of health information technologies. I just don’t think that changing the reimbursement structures are the best way to go about achieving these goals.
Thought for the day
One size does not fit all.

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