1) A reader writes: “Physician orders a CT scan for patient. The powers that be at [the insurance company], refuse to pre-certify the request and deny the test. Next, patient goes to the emergency room and the ER physician orders the CT scan. Now, [the insurance company] has to pay ER fees, ER physician fee, radiologist fee and any other costs. The overall cost is now probably 1-2 thousand dollars instead of a couple hundred bucks, if the original CT request had been pre-certified.

Can I have your take on the seemingly illogical reasoning at [the insurance company]?”

This happens all the time, and shows the unintended consequences of pre-certification for imaging tests. Providers who don’t want deal with pre-certs simply sends the patient to the emergency room.

With a number emergency room physicians practicing scared, the desired study will be ordered. Since it was ordered in the emergency setting, pre-certification isn’t needed.

Requiring pre-certification incentivizes physicians to send patients to the ED for tests, resulting in higher cost care. My guess is that the insurers are banking that providers won’t resort to that, but so far, they’re wrong.

2) JCAHO is mandating better behavior in the health care setting.

This needs to be especially applied in the academic setting, where the climate is more hierarchical. Interns and residents play a critical role in patient care, so allowing them to comfortably speak out when they see errors or disruptive behavior is crucial.

As I commented in the linked piece, it’s a good idea, but it has to be enforced for it to be meaningful.

3) A reader writes: “How do you decide who makes it into the MedBlog Power 8?”

Here’s how I come up with the weekly Power 8:

i) I take a close look at all the current blogs on the Power 8 and decide who stays for the new list, and who goes.

ii) After determining who stays (normally 4-5 blogs), I go through my feeds page and e-mail suggestions for the 2-3 spots that are left. In a typical week, about 20+ blogs are considered for these spots.

iii) I review and consider every blog that is suggested to me via e-mail.

iv) As stated previously, factors I consider are how provocative the posts are, the amount of discussion it generates, and posting frequency. Blogs that are well-written, easy to read, takes a measured tone, and doesn’t ramble are favored.

Want my take? E-mail a topic or question you want me to blog about. Selected entries will be posted in the regular “My Takes” feature.