Author Believes Clinically Aware Benefit Plans Are Advantageous

OPINION -- February 22, 2012 -- Even before the Patient Protection and Affordable Care Act was written, coverage designed to avoid sick patients was becoming an unacceptable goal. A goal that most commercial benefit plans and claim processing systems use, assuming predominantly healthy populations, and preventing those that need the coverage the most from being adequately addressed.

Payment management for a population of sick patients requires clinically aware benefit plans. Plan coverage should expand to appropriately recognize and include specific conditions; conditions that require more resources to manage. At the same time, identified insignificant clinical conditions should get reduced attention.

Explicit inclusion of clinical coverage decisions in the benefit plan mHake them more transparent, predictable and manageable. The need of medical necessity review and determination is reduced along with the time and expertise required to adequately perform the task. Payments become more predictable and timely.

The Oregon Health Plan is an early example of a clinically aware benefit plan. The emphasis on funding, and debates about rationing distracts from this fact, and has obscured and weakened its prescient nature. This hidden attribute can be brought to the forefront by employing a claims adjudication engine designed to take advantage of the clinical data the plan already exposes.

Coupled with a payment method that uses the clinical data to provide actuarially sound, predictable, adaptations to important patient conditions, and the plan becomes more efficient and effective. This type of process enables interested regional plans serving the Oregon Health Plan market to expand their offerings with a more flexible and affordable exchange-based coverage.

Dr. Rohwer is chief executive officer of Perfomance Health Technology Ltd., and former medical director of Mid-Valley IPA. He also practiced medicine in Salem for 20 years.

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Something about claims adjudication has always bothered me: Why do we allow non-medically trained claims adjusters to overrule the physician who has examined the patient? Clinical guidelines are intended to help, not hinder, the physician. If the insurer trusts the physician enough to include them in their provider network, they should abide by their treatment decisions. Does anyone know how many millions of dollars would be saved if we didn't have claims adjusters, appeal procedures and hearings officers?