The Centers for Disease Control and Prevention has released an online quiz to help adolescents and adults identify the vaccines they may need. The quiz generates a list of recommended vaccines based on the respondent’s gender, age, lifestyle, work and health status, which they can discuss with their health care provider.
Take quiz here.
Friday, August 3, 2007
URAC Releases First Ever Pharmacy Benefit Management Standards
[Source: Health Lawyers Weekly, August 3, 2007]
URAC, an independent accreditor of healthcare management organizations, released July 27 the first-ever voluntary accreditation standards for pharmacy benefit management organizations.
The Pharmacy Benefit Management Accreditation program includes modules for organizational quality, customer service, communications, disclosure of pricing policies, pharmaceutical distribution, drug utilization management, and formulary/pharmacy and therapeutics committee, URAC said in a press release.
“The standards address key areas for any pharmacy benefit organization, but allow for innovation,” said John Jones, RPh, JD, chairman of URAC’s PBM Standards Committee and vice president of professional practice and pharmacy policy at Prescription Solutions. “Clinical rigor, such as the qualifications of staff who make decisions about drugs included in a formulary and how those decisions are made, is one notable area. The standards also seek a very sound operational base and address regulatory compliance issues, such as oversight of information disclosure to consumers, providers and pharmacists.”
“The accreditation program is really focused on making sure organizations do what is right by the consumer, including standards for appeals procedures and making sure they have access to the drugs they need,” Jones added.
The release also noted that the program underwent a rigorous field testing process, with more than 53% of the market participating in the testing.
Read URAC’s press release.
URAC, an independent accreditor of healthcare management organizations, released July 27 the first-ever voluntary accreditation standards for pharmacy benefit management organizations.
The Pharmacy Benefit Management Accreditation program includes modules for organizational quality, customer service, communications, disclosure of pricing policies, pharmaceutical distribution, drug utilization management, and formulary/pharmacy and therapeutics committee, URAC said in a press release.
“The standards address key areas for any pharmacy benefit organization, but allow for innovation,” said John Jones, RPh, JD, chairman of URAC’s PBM Standards Committee and vice president of professional practice and pharmacy policy at Prescription Solutions. “Clinical rigor, such as the qualifications of staff who make decisions about drugs included in a formulary and how those decisions are made, is one notable area. The standards also seek a very sound operational base and address regulatory compliance issues, such as oversight of information disclosure to consumers, providers and pharmacists.”
“The accreditation program is really focused on making sure organizations do what is right by the consumer, including standards for appeals procedures and making sure they have access to the drugs they need,” Jones added.
The release also noted that the program underwent a rigorous field testing process, with more than 53% of the market participating in the testing.
Read URAC’s press release.
Tennessee Appeals Court Rules Physicians Must Arbitrate Claims Against BlueCross
[Source: Health Lawyers Weekly, Vol. 4, Issue 47]
Two physicians who alleged that a health insurer systematically and arbitrarily denied payments to them and other similarly situated doctors cannot sue, but instead must submit to binding arbitration in accordance with their participating provider agreements, the Court of Appeals of Tennessee ruled November 29.
Zachary Rosenberg, M.D. and Dewayne P. Darby M.D. (plaintiffs) entered into participating provider agreements with BlueCross BlueShield of Tennessee (BCBST). These agreements set forth a dispute resolution process requiring the parties to submit unresolved claims to binding arbitration, in accordance with the Tennessee Uniform Arbitration Act.
Plaintiffs sued BCBST, alleging breach of contract, unfair or deceptive business practices, and other claims based on fourteen different types of allegedly improper conduct, including bundling, downcoding, and physician profiling.
In their complaint, plaintiffs sought relief not only for payments denied them, but also for punitive damages and injunctive relief on behalf of the class of all BCBST participating providers.
BCBST moved to compel arbitration. Plaintiffs opposed, arguing that the arbitration procedure contained in their participating provider agreements was unenforceable because it was cost prohibitive. In particular, plaintiffs argued that the cost of arbitrating the physicians’ small individual claims would be cost prohibitive, so as to deny them a viable remedy.
The trial court rejected that view and ruled plaintiffs failed to demonstrate that the cost of arbitration would be prohibitively more expensive than a judicial forum.
On interlocutory appeal, the Court of Appeals of Tennessee opined, “Seldom has a time-honored rule of common law been so decisively reversed and supplanted by an even stronger statutory mandate to the contrary than is evidenced by the present exalted status of arbitration.”
Reviewing the arbitrability issue de novo, the court cited the U.S. Supreme Court decision in Green Tree Financial v. Randolph, 531 U.S. 79 (2000), as a “starting point,” and conducted a close review of federal and state law concerning the impact of potentially cost-prohibitive arbitration.
The party seeking to avoid arbitration must bear the burden of proving that arbitration is cost prohibitive, the appeals court explained.
In the case at bar, plaintiffs asserted that their claims are of minimal value, even if aggregated over two years. If that were the case, the appeals court reasoned, “it would be easy enough to say on very limited proof that arbitration was cost prohibitive. The complaint, however, asserts no such small claims but rather alleges a pattern of improper and deceptive conduct and business practices,” costing millions of dollars, plus punitive damages, fees, and permanent injunctive relief.
“What might be prohibitive when a $4,000 claim is in issue would certainly not be prohibitive when millions of dollars and vast injunctive relief are actually in issue,” the appeals court determined. Thus, plaintiffs failed to meet their burden of proof.
“A party challenging the arbitration provisions of a contract, particularly when those provisions are clear and unambiguous, faces a figurative tsunami of case law, both federal and state, ever strengthening and reinforcing the favored status of arbitration.”
Because federal and state law strongly favor arbitration, and the participating provider agreement requires all disputes to be subject to binding arbitration, the appeals court agreed with the trial court, which had granted the motion to compel arbitration.
Rosenberg v. BlueCross BlueShield of Tenn., No. M2005-01070-COA-R9-CV (Tenn. Ct. App. Nov. 29, 2006).
*****
Note:
Tennessee's Uniform Arbitration Act:
Tenn. Code, Title 29, Ch.5, Part 3, §§ 301 to 320
Two physicians who alleged that a health insurer systematically and arbitrarily denied payments to them and other similarly situated doctors cannot sue, but instead must submit to binding arbitration in accordance with their participating provider agreements, the Court of Appeals of Tennessee ruled November 29.
Zachary Rosenberg, M.D. and Dewayne P. Darby M.D. (plaintiffs) entered into participating provider agreements with BlueCross BlueShield of Tennessee (BCBST). These agreements set forth a dispute resolution process requiring the parties to submit unresolved claims to binding arbitration, in accordance with the Tennessee Uniform Arbitration Act.
Plaintiffs sued BCBST, alleging breach of contract, unfair or deceptive business practices, and other claims based on fourteen different types of allegedly improper conduct, including bundling, downcoding, and physician profiling.
In their complaint, plaintiffs sought relief not only for payments denied them, but also for punitive damages and injunctive relief on behalf of the class of all BCBST participating providers.
BCBST moved to compel arbitration. Plaintiffs opposed, arguing that the arbitration procedure contained in their participating provider agreements was unenforceable because it was cost prohibitive. In particular, plaintiffs argued that the cost of arbitrating the physicians’ small individual claims would be cost prohibitive, so as to deny them a viable remedy.
The trial court rejected that view and ruled plaintiffs failed to demonstrate that the cost of arbitration would be prohibitively more expensive than a judicial forum.
On interlocutory appeal, the Court of Appeals of Tennessee opined, “Seldom has a time-honored rule of common law been so decisively reversed and supplanted by an even stronger statutory mandate to the contrary than is evidenced by the present exalted status of arbitration.”
Reviewing the arbitrability issue de novo, the court cited the U.S. Supreme Court decision in Green Tree Financial v. Randolph, 531 U.S. 79 (2000), as a “starting point,” and conducted a close review of federal and state law concerning the impact of potentially cost-prohibitive arbitration.
The party seeking to avoid arbitration must bear the burden of proving that arbitration is cost prohibitive, the appeals court explained.
In the case at bar, plaintiffs asserted that their claims are of minimal value, even if aggregated over two years. If that were the case, the appeals court reasoned, “it would be easy enough to say on very limited proof that arbitration was cost prohibitive. The complaint, however, asserts no such small claims but rather alleges a pattern of improper and deceptive conduct and business practices,” costing millions of dollars, plus punitive damages, fees, and permanent injunctive relief.
“What might be prohibitive when a $4,000 claim is in issue would certainly not be prohibitive when millions of dollars and vast injunctive relief are actually in issue,” the appeals court determined. Thus, plaintiffs failed to meet their burden of proof.
“A party challenging the arbitration provisions of a contract, particularly when those provisions are clear and unambiguous, faces a figurative tsunami of case law, both federal and state, ever strengthening and reinforcing the favored status of arbitration.”
Because federal and state law strongly favor arbitration, and the participating provider agreement requires all disputes to be subject to binding arbitration, the appeals court agreed with the trial court, which had granted the motion to compel arbitration.
Rosenberg v. BlueCross BlueShield of Tenn., No. M2005-01070-COA-R9-CV (Tenn. Ct. App. Nov. 29, 2006).
*****
Note:
Tennessee's Uniform Arbitration Act:
Tenn. Code, Title 29, Ch.5, Part 3, §§ 301 to 320
Calif. Supreme Court to consider line between discrimination, physicians' religious freedom.
[Source: Health and Life Sciences Law Daily, August 3, 2007]
USA Today (8/3, Parker) reports, "The California Supreme Court is being asked to answer that question when it hears a legal dispute between a lesbian mom," Guadalupe Benitez, and two doctors "who refused to artificially inseminate her for religious reasons." The high court "is being asked to decide how to accommodate a physician's religious views without violating California's anti-discrimination laws." USA Today notes, "The dispute arose in 2000 after San Diego-area doctors Christine Brody and Douglas Fenton refused to artificially inseminate Benitez." The doctors "say in court papers that they refused to treat Benitez because she is unmarried, not because she is gay." Said to be the first of its kind, the case "is shaping up as one of the most controversial before the court in years. Jill Morrison, legal counsel to the National Women's Law Center, noted that a distinguishing factor of Benitez's case "is that the physicians involved refused to provide a medical procedure to one patient that they readily provide to others." Morrison said, "Usually, providers who object to certain services object to them for everyone: 'I won't provide contraception.' In this case, they don't object to the service, just the patient. You can't pick and choose. You can't say, 'I will perform it for white people, but not for black people.'" Meanwhile, Kenneth Pedroza, the doctors' attorney, "counters that an 'all-or-nothing' rule will drive physicians out of certain specialties." USA Today (8/3, 1A) also notes the number of states that allow healthcare professionals to refuse to provide certain services.
****
From USA Today:
Number of states that allow health care professionals to refuse to provide these services:
•46 — abortions
•17 — sterilization
•13 — contraceptives
[Source: Guttmacher Institute]
USA Today (8/3, Parker) reports, "The California Supreme Court is being asked to answer that question when it hears a legal dispute between a lesbian mom," Guadalupe Benitez, and two doctors "who refused to artificially inseminate her for religious reasons." The high court "is being asked to decide how to accommodate a physician's religious views without violating California's anti-discrimination laws." USA Today notes, "The dispute arose in 2000 after San Diego-area doctors Christine Brody and Douglas Fenton refused to artificially inseminate Benitez." The doctors "say in court papers that they refused to treat Benitez because she is unmarried, not because she is gay." Said to be the first of its kind, the case "is shaping up as one of the most controversial before the court in years. Jill Morrison, legal counsel to the National Women's Law Center, noted that a distinguishing factor of Benitez's case "is that the physicians involved refused to provide a medical procedure to one patient that they readily provide to others." Morrison said, "Usually, providers who object to certain services object to them for everyone: 'I won't provide contraception.' In this case, they don't object to the service, just the patient. You can't pick and choose. You can't say, 'I will perform it for white people, but not for black people.'" Meanwhile, Kenneth Pedroza, the doctors' attorney, "counters that an 'all-or-nothing' rule will drive physicians out of certain specialties." USA Today (8/3, 1A) also notes the number of states that allow healthcare professionals to refuse to provide certain services.
****
From USA Today:
Number of states that allow health care professionals to refuse to provide these services:
•46 — abortions
•17 — sterilization
•13 — contraceptives
[Source: Guttmacher Institute]
Physicians, executives indicted for selling prescription drugs via Internet.
[Source: Health and Life Sciences Law Daily, August 3, 2007]
The AP (8/3, Hoffman) reports, "Physicians and executives are among 18 people accused of selling prescription drugs over the Internet to people without any examinations, according to an indictment unsealed Thursday that charges them with federal racketeering." The 313-count indictment denotes "the first time organized-crime statutes designed to combat drug cartels and mafia rings have been used to charge anyone with selling prescription drugs over the Internet." Costa Rica-based AffPower allegedly "took more than 1 million orders for legal pharmaceuticals including diet pills," and "birth control pills" between "August 2004 and June 2006," and "the total value of the drugs sold exceeds $126 million." The indictment also says that doctors "were paid $3 for each order reviewed," and "approved hundreds or even thousands of orders a day." The prescriptions "were then filled through licensed online and brick-and-mortar pharmacies, who received between $5 and $13 for each order."
The AP (8/3, Hoffman) reports, "Physicians and executives are among 18 people accused of selling prescription drugs over the Internet to people without any examinations, according to an indictment unsealed Thursday that charges them with federal racketeering." The 313-count indictment denotes "the first time organized-crime statutes designed to combat drug cartels and mafia rings have been used to charge anyone with selling prescription drugs over the Internet." Costa Rica-based AffPower allegedly "took more than 1 million orders for legal pharmaceuticals including diet pills," and "birth control pills" between "August 2004 and June 2006," and "the total value of the drugs sold exceeds $126 million." The indictment also says that doctors "were paid $3 for each order reviewed," and "approved hundreds or even thousands of orders a day." The prescriptions "were then filled through licensed online and brick-and-mortar pharmacies, who received between $5 and $13 for each order."
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