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!
My longtime collaborator, Jim Beattie, and I will be taking our roadshow to Cleveland, Ohio, for the Midwest Chapter of the Medical Library Association’s Annual Conference. Our four-hour workshop (sounds long, goes fast) provides a practical introduction to evidence-based medicine (EBM). The material is adapted from courses that we teach at University of Minnesota and prior MLA conference presentations. This blog post serves as our “course website.”