In one of my lives (I have a few), I serve as the medical director for a commercial health plan. My duties involve developing policies and reviewing claims. It’s the greatest job on earth if you love evidence-based medicine (which I do!). And it connects perfectly to another life: teaching EBM at the University of Minnesota, which I’ve been doing since 2004.
I’m pleased to return to St. Joseph’s Hospital, my former employer and postgraduate alma mater, on August 20th to discuss health insurance with the family residents.
This post contains my key teaching points and didactic materials.
Suggested Thought Process
Is the health care service a covered benefit? (cf. benefit plan)
Does the carrier have a policy concerning the health care service?
In the absence of a specific policy, is the health care service medically necessary?
Does the member (patient) and/or evidence meet criteria?
At a very high level, benefits are determined by the member’s benefit plan. Eligible services are subject to the plan’s terms, as often summarized in medical policies. Excluded services are not eligible for coverage and cannot be funded by the plan (doing so would violate a contact with the plan’s owner).
Opioids are a common and sometimes uncomfortable area where law and medicine intersect. For years, I’ve been extolling the virtues of the Federation of State Medical Boards’ “Model Policy” as a means for mitigating risk. It also serves as an excellent framework for approaching opioid-related incidents and investigations.
The Model Policy first appeared in 1998 and is now in its fourth edition (2017). Section 3 provides detailed guidance on patient selection, informed consent, medication agreements, drug testing, and so forth.
Adhering to the Model Policy ensures patient safety but also provides a safe harbor against enforcement actions. For example, the Minnesota Board of Medical Practice typically includes this condition in opioid-related discipline:
Respondent shall read the Federation of State Medical Boards’ “Model Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain”
Adhering to the Model Policy is a good way to avoid being investigated. And acknowledging the Model Policy and demonstrating compliance with it are an effective means to respond to questions about care.
Many thanks to Kevin Riach and Joe Dixon, shareholders at Fredrikson & Byron, for including me in this event. And I hope to see you there!
I’m pleased to be partnering with Allina Health’s hospitalists on education and order set creation. The latter includes a presentation at their annual CME conference, offered on a repeating basis on April 5th, April 10th, April 26th and May 2nd.
Hospitalists frequently care for patients following overdoses and other opioid-related misadventures—trauma, endocarditis, and so on. Buprenorphine is a very nifty widget in these circumstances.
Another common scenario is acute pain management for patients who take buprenorphine in the community. Pain control is neither hard nor complicated, so long as you follow a few simple rules.
Special thanks to Drs. Saul Singh and David Beddow for their partnership on this.
The Saint Cloud Timesrecently featured CentraCare Health’s correctional care (“jail medicine”) program. This unique public-private partnership is designed to identify and treat mental illness and addiction while inmates are in custody. We then link them to a special clinic following release to the community for ongoing management. (I serve as the medical director for the program.)
We launched in the Benton County Jail on October 1st, 2017, and in the Stearns County Jail on January 1st, 2o18. As outlined in the article, the early signals are promising: fewer ambulance trips between the jail and hospital, fewer detox admissions and decreased total cost of care.
As far as we know, we’re the only Minnesota counties starting inmates on Suboxone, the medication to treat opioid addiction, while in custody. And, one needs to look far and wide to find other examples nationally.
Providers see inmates in jail and following release to the community. This continuity of care is unprecedented. Health authorities (a statutory term) have historically focused on inmates’ immediate medical needs in jail without regard for the bigger picture. This penny-wise but pound-foolish approach doesn’t resolve some big reasons—mental illness and addiction— for criminal recidivism. Thus the revolving door.
Special thanks to my partners in crime (sorry! couldn’t stop myself):
Two years ago today, North Memorial Health opened its Mental Health & Addiction Center. Previously, it didn’t have an outpatient clinic for medication management and psychotherapy, or to receive patients following hospital discharge.
Kelly Macken-Marble and I served as the project’s executive sponsors. In truth, John Sutherland, Jackie Dean, David Oliver and Marrion Muia did all of the work. And, boy, was it a lot of work! The project involved everything from architectural drawings to clinical workflows—literally thousands of hours, decisions and details.
KSTP’s Ken Barlow, who has bravely and very publicly shared his brush with bipolar disorder, was the master of ceremony. A good time was had by all.
Middle Left: John Sutherland and Jackie Dean cutting the ribbon. Middle Right: Ken Barlow. Bottom Left: Ken Barlow; David Frenz; and Brian Johns, M.D.
This week, we paused from life’s bustle to celebrate a remarkable public-private partnership. CentraCare Health, based in St. Cloud, Minn., began discussing correctional health care (“jail medicine”) with its host counties about three years ago. This ultimately resulted in CentraCare being named as the health authority (a statutory term) for the Benton County Jail and Stearns County Jail.
I’m fortunate to be part of the team that spun up the program. Originally, it was just Katy Kirchner, Heather Qunell, Cindy Henze and me squatting in a vacant office. There were only two desks, so I typically sat on the floor with my laptop.
The program also owes its success to incredible nurses and support staff, and unwavering executive support. On the CentraCare side, Kelly Macken-Marble and Kathy Parsons have championed the partnership. And from the counties, Captains Susan Johnson (Benton) and Mark Maslonkowski (Stearns), the jail administrators, have been fantastic colleagues.
Many thanks to CentraCare for involving me in this deeply rewarding opportunity! §