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Managed Care Partners - Bits, Bytes, and Briefs

Managed Care Partners Winter 2012

Bits, Bytes, and Briefs

Date: January 3, 2012

Jettisoning jargon

A report from the National Assessment for Adult Literacy indicates that two out of five Americans are stymied when trying to obtain and understand the basic health information and services they need. Such health care illiteracy is costly. Research by the nonprofit Center for Health Care Strategies suggests that it costs the U.S. economy between $106 billion and $203 billion a year.

According to Beth Bierbower, CEO of Humana Specialty Benefits, inability to understand what a health plan offers or what medical care entails “leads to less compliance with prescribed treatment instructions, more errors with medicine, failure to seek preventive care, longer hospital stays and higher risk for hospitalization in general.”

Writing in Managed Healthcare Executive, Bierbower says employers should use “straightforward, jargon-free content” in all of their communications to employees about health benefits options to help enrollees better understand and engage in their benefits. She says plain language could also reduce the administrative costs associated with misinterpretation of coverage. Among the examples she suggests are using the word doctor instead of primary care physician and the word drugs instead of prescription medication.

P4P may be kaput

The pay for performance (P4P) method that managed care plans have long used to compensate hospitals and physicians for the service they provide may be on its way out, as paying for improved patient outcomes (P4O) is being promoted by the federal Centers for Medicare and Medicaid Services (CMS).

 CMS has stopped paying for so-called never events, or egregious medical errors that never should have occurred, such as surgery on the wrong site of the patient’s body, and health care plans have followed suit. More efforts are expected to link compensation to improved patient safety and satisfactory clinical outcomes.

The trend likely will accelerate when CMS stops paying hospitals that don’t meet specific quality measures and expected clinical outcomes—and health plans emulate that change as well.

Tiger syndrome?

The American Psychological Association is conducting in-depth discussions on what activities and obsessions may qualify for inclusion in the new fifth edition of the Diagnostic and Statistical Manual of Mental Disorders—known as DSM-5 for short—which is scheduled for publication in 2013.

Among the possible new conditions may be hypersexual disorder, which some psychologists and psychiatrists have associated with Tiger Woods’ much-publicized infidelities. A practitioner could diagnose the disorder if a person spends an “excessive” amount of time fantasizing about or planning for sex, particularly if such fantasizing or planning seems to be linked to anxiety, depression, irritability or boredom.

Other potential changes in the DSM-5 could establish new criteria for diagnosing binge eating, type II bipolar disorder, Asperger’s syndrome and many more conditions.

When the DSM-5 is completed, such changes could have a significant effect on who gets insurance coverage for these and other conditions. Contesting the validity of a condition in the DSM may be difficult, but it’s not impossible—and some groups in the past have argued that expanding the DSM’s designation of disorders gives practitioners the opportunity to bill for treating controversial conditions.

Since addressing mental health issues, many of which now are recognized as biologically based, has become an accepted part of overall health care coverage, however, insurers are less likely to question the validity of conditions that previously had been treated in conjunction with other problems.

Under the 2008 Mental Health Parity and Addiction Equity Act, which became fully effective in 2010, if a health plan covers services for mental health and substance abuse at all, financial or treatment limits on those services cannot be any more restrictive than those imposed for medical or surgical benefits covered under the same plan. Should the Affordable Care Act, the health care reform law, go into effect fully in 2014, substantial increases in mental health coverage also will become mandatory.