Weekend update

Congress remains on the campaign trail this week.

Last Friday, OPM released its 2014 Government-wide Federal Employee Viewpoint Survey results. This report concerns employee attitudes toward their jobs, Federal New Radio has a two useful articles that review and analyze the survey results.

At last week’s Express Scripts conferernce, I heard a futurist J.D. Kleinke express his opinion that the cost curve is down because of among other factors a public backlash against high cost care, e.g., see use of retail clinics. Of course, health plans are in the vanguard encouraging this trend. According to this Fierce Health Payer article, insurers are pushing back against “Rolls Royce” treatments. However, because no good deed goes unpunished, members of the FEHBlog’s profession, who represent the doctors are criticizing this practice:

“I think the Affordable Care Act has really helped in many ways,” William Shernoff, a healthcare attorney in Beverly Hills, California, told the Daily News. “But I think they left one big loophole.”

Shernoff is referring to the fact that the ACA allows insurers to deny procedures, even ones recommended by doctors, if they consider them unreasonable or not up to the standard of care. “There doesn’t seem to be anything in the ACA that lays down any guidelines or standards on who determines medical necessity,” he added.

The FEHBlog considers this quite an overstatement because the ACA requires that all plan member disputes over medical necessity decisions be referred to an independent decision maker. In the case of the FEHBP, that decision maker is OPM. Could it be that the independent decision makers are siding with the plans? The FEHBlog would not be surprised to learn that. 

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