25 minute read
DANIEL J. SCHULTE, JD
from MI MEDICINE
The 90-Day Myth with Unemployment Claims
By Jodi Schafer, SPHR, SHRM-SCP, Human Resources Management Services, LLC
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Q : I have an employee who
I recently hired, but after two months on the job, she is still making errors. I just don't think she is going to work out, so it looks like I will be terminating her. She's trying hard but does not seem to be able to catch on to the way we do things. Since she's only been with me for such a short time, I don't have to worry about an unemployment claim against me, right? I thought I had a 90-day window to decide if I want to keep her before I had to worry about unemployment compensation, but I wanted to doublecheck before I make any decisions.
If you terminate her, she has every right to file a claim for unemployment. Whether she receives it or not, has to do with how much money she earned in the previous year and the reason she is out of work rather than how long she was employed with your practice.
The Unemployment Insurance Agency (UIA) uses a two-tiered test based on eligibility and qual ification to determine if a person will receive compensation. First, the UIA must determine if the individual is ‘eligible’ for benefits. To be eligible in Michigan, a person must meet an earn ings threshold within an established period of time. The UIA establishes a ‘base period’ by looking backwards at the last 4-5 quarters of the current/pre vious calendar year(s). Within this base period, the claimant must have:
wages in at least 2 quarters, and
wages in the highest quarter of earnings of at least $3,744 (as of 1/1/20), and
wages in the entire base period that are at least 1.5 times the wages earned in the highest quarter. Or, within this same base period, the claimant must have:
wages in at least 2 quarters, and
wages in the entire base period that equal at least 20 times the state weekly average wage or $20,742.
For the purposes of wage calculations, the UIA considers wages from ALL employers the claimant worked for during the established base period. If the claimant is determined to be eligible for benefits, the UIA will next decide whether or not they are ‘qualified’ to make a claim. To be qualified, the unemployed person must:
have lost their job through no fault of their own, and
be able and available for work, and
be actively looking for work.
There are a number of other rules and formulas that are involved with the determination of the claim, but the UIA will send letters to you (the previ ous employer) along the way to inform you if a claim was filed and the infor mation required of you in response.
If you do decide to terminate her and she does apply for unemployment (assuming she was deemed eligible to do so by the UIA), you can still choose to contest the claim based on the reason she is no longer working for your practice. You will need to prove that her inability to perform the work demonstrated a willful dis regard for your best interest. This will be difficult to do since it sounds like her lack of skill was not the result of an overstatement of her abilities in her resume or an interview, nor was it the result of a conscious choice to neglect her duties. As you state, “she's trying hard but does not seem to be able to catch on to the way we do things,”. Therefore, the UIA may determine that she is out of work through no fault of her own. Remem ber it is called unemployment insurance rather than employer insurance and it was designed to give the unem ployed individual the advantage.
Let’s take a step back for a minute though. Are you really sure you want to get rid of this employee? You may want to start the training all over again, documenting the process and giving her copies of this documenta tion. Remember, people learn differently. It may just take her longer to learn. Try to offer her the information in different ways. She may need an other person training her. Two months is not that long of a period of time, es pecially if she did not come with any experience. Make sure that you give her every opportunity to succeed. The labor market is very tight right now and you may find it challenging to find someone else for the job.
Protecting Michigan’s Infants and Young Children from Vaccine-Preventable Diseases
By Stefanie Cole, BSN, RN, MPH, Pediatric Immunization Nurse Educator, Michigan Department of Health and Human Services, Division of Immunization
Since 1994, the United States has recognized one week of the year as National Infant Immunization Week (NIIW) to highlight the importance of protecting infants from vaccine-preventable diseases and to celebrate achievements of immunization programs and partners in promoting healthy communities. 1
While it is certainly important to have a dedicated time during the year to remember how vital vaccines are to protecting young children’s health, it’s even more important that pediatric healthcare providers put that into practice throughout the entire year. Infants are especially vulnerable to vaccine-preventable diseases and their associated complications. Luckily, we have vaccines available to help keep children healthy in those first important years of life.
Vaccines protect against 14 diseases by the age of 2 years. For best protection, healthcare providers should immunize their patients according to the Advisory Committee on Immunization Practices (ACIP) immunization schedules. 2 Both the child/ adolescent and adult immunization schedules are updated annually and were recently updated in February 2020. Vaccines should be administered at the recommended ages. Because so many vaccine series require multiple doses for full protection, if a child falls behind on the recommended schedule it can be difficult to get them caught back up in a timely manner.
According to Michigan Care Improvement Registry (MCIR) data as of November 2019, 84.1% of Michigan infants had re
ceived their first dose of hepatitis B vaccine by 1 month of age. Hepatitis B vaccine is recommended to be given to all infants shortly after birth (within 12 or 24 hours, depending on the mother’s hepatitis B status). Not only does this mean that about 16% of 1-month-olds are left completely vulnerable to hepatitis B during their first month of life, but it becomes that much harder once beginning the hepatitis B vaccine series to receive all the doses on time according to the schedule. Furthermore, there is a concerning decline in the percentage of Michigan infants between 1 and 7 months of age who are completely vaccinated according to the recommended schedule. By age 7 months, only 54.2% of Michigan children are completely up to date with all recommended vaccines (excluding influenza). By age 2 years, only 52.5% of Michigan children are complete up to date with recommended vaccines. These data show that once children fall behind on their immunization schedule, they often do not get completely caught back up. Again, these are alarming statistics because young children, especially those less than 2 years old, are at higher risk for acquiring and becoming very ill from vaccine-preventable diseases. Many vaccine-prevent
able diseases such as pertussis (whooping cough), varicella (chickenpox), and mumps circulate in Michigan every year. 3 Although influenza affects more people than any other vaccine-preventable disease, many Michiganders go unprotected from flu. As of December 31, 2019, only 5.6% of Michigan children aged 6 months through 8 years recommended to receive two doses of flu vaccine for full protection during the 2019-20 season had received both doses. 4
Other diseases we typically see less often in Michigan but are just a plane ride away. In 2019, there were 46 confirmed cases of measles in Michigan, more than the state has experienced since 1991. 5 More than 1,200 cases of measles were confirmed in the U.S. in 2019, the greatest number of cases reported since 1992. 6 Michigan’s large measles outbreak as well as the majority of the nation’s measles cases last year were associated with unvaccinated individuals who travel internationally and bring measles back home where it spreads in communities with pockets of unvaccinated people. Measles is currently a global public health threat with many countries around the world experiencing outbreaks. As of November 5, 2019, there were more than 413,000 confirmed cases reported to the World Health Organization. 7 In the Democratic Republic of Congo alone, about 310,000 suspected measles cases have been reported since the beginning of 2019 with over 6,000 deaths. 8 Remember there are situations where children should be vaccinated earlier than the routinely recommended age. Children aged 6-11 months who travel internationally should be vaccinated against measles and hepatitis A before departure.2 Refer back to the immunization schedules to ensure you fully protect your youngest patients from vaccine-preventable diseases. Keep them healthy by keeping them on the recommended vaccine schedule.
REFERENCES
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4 5 6
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8 Centers for Disease Control and Prevention (2019). NIIW (National Infant Immunization Week). Retrieved from www.cdc.gov/vaccines/events/niiw/index.html on January 27, 2020. Centers for Disease Control and Prevention (2019). Immunization Schedules. Retrieved from www.cdc.gov/ vaccines/schedules/index.html on January 27, 2020. Michigan Department of Health and Human Services (2020). Vaccine Preventable Diseases in Michigan – Annual Summaries. Retrieved from www.michigan.gov/ mdh-hs/0,5885,7-339-73971_4911_4914_6385-47024--, 00.html on January 27, 2020. Unpublished MDHHS data. Provisional data. Centers for Disease Control and Prevention (2020). Measles Cases and Outbreaks. Retrieved from www.cdc. gov/measles/cases-outbreaks.html on January 28, 2020. World Health Organization. (2020). Measles – Global situation. Retrieved from www.who.int/csr/don/26-november-2019-measles-global_situation/en/ on January 28, 2020. Center for Infectious Disease Research and Policy. (2020). As measles deaths top 6,000 in DRC, WHO calls for aid. Retrieved from www.cidrap.umn.edu/news-perspective/2020/01/measles-deaths-top-6000-drc-whocalls-aid on January 28, 2020.
Spotlight on Senator Curt VanderWall
Patients are nearer each day to meaningful prior authorization and step therapy reforms thanks to the work of diligent patient advocate in the state legislature, led by Senator Curtis VanderWall.
Senator VanderWall is both the Chairman of the Senate Health Policy and Human Services Committee and the sponsor of Senate Bill 612, a reform that would shorten patients’ wait for the treatment, medicine, and testing or dered by their health care providers.
“The term “prior authorization” refers to the process insurance companies use to determine whether an enrollee is eligible to have certain health care ser vices, procedures, or prescription drugs covered by insurance,” said Senator VanderWall. “Unfortunately, the prior authorization process has created bar riers and inefficiencies regarding access and quality of care in the health care system. Several of my own constituents have told me accounts of how this pro cess has endangered their health.”
VanderWall represents a wide swath of northern lower Michigan, includ ing Benzie, Crawford, Kalkaska, Lake, Leelanau, Manistee, Mason, Missau kee, Ogemaw, Osceola, Roscommon and Wexford counties. Before coming to Lansing, he made his living as the owner of Turf Care Mole Man of Lud ington, and worked much of his life at Eberhard Foods and Prevo’s Family Market. He understands the importance of meeting the needs of everyday Mich iganders – he made a career out of it.
When patients reached out to his office to share difficult experiences they’d had obtaining the prescrip tions and the medical treatment they needed because of onerous insurance company practices, VanderWall got to work on a solution. The result is Senate Bill 612, a reform that’s already gained bipartisan co-sponsorship, and numerous hearings in Lansing .
“Senate Bill 612 would reform the prior authorization process to facilitate transparency, improve access to care and eliminate some of the burdens that exist,” said VanderWall.
“For patients, this bill would improve their ability to receive prompt access to necessary care by reducing the review timeframes permitted for insurance companies to make determi nations for standard and urgent prior authorization requests.
Thanks to his leadership, patients, physicians, health care providers, and patient advocacy organizations have had the repeated opportunity to speak directly to lawmakers, to share their stories, and to fight for prior authoriza tion and step therapy reforms.
VanderWall encourages everyone affected by prior authorization and step therapy delays to contact their state Senators and Representatives and ask them to support SB 612. They and others can thank Senator VanderWall for his leadership in this fight, too, by visiting his website: http://senatorcurtvanderwall.com/contact.
Making Progress in the Fight to Reform Prior Authorization and Step Therapy
Like many people, Lyndsey Crosbie would occasionally take Advil for pain relief. Unlike many people, it took two visits to the emergency room before Lyndsey and her physician realized that was a bad idea.
The solution then was simple: Lyndsey would be prescribed a new medication as a replacement for NSAIDs, one that does not typically cause allergic reactions to those with NSAID allergies.
Her insurance company denied the new prescription.
Thankfully, Lyndsey’s physician was able to get the issue resolved in short order. But the relief was just temporary.
It’s a story that reads like a Joseph Heller novel—a Catch-22 that seems too ridiculous to be real.
But it is.
Lyndsey’s story is all too real, and one that’s too familiar for a lot of patients here in Michigan. It’s a tale about prior authorization, step therapy and the wedge insurance company practices create between phy sicians and the patients they’re trying to help.
It’s not all bleak though. Michigan phy sicians, patients and patient advocates have banded together and found a bet ter way forward. There’s only one thing left to do: convince lawmakers they’ve got it right.
Senate Bill 612, currently being con sidered by the Senate Health Policy and Human Services Committee, intro duces new transparency and clinical validity requirements that would pro tect patients from costly and dangerous delays in access to health care, ensur ing stories like Lydney’s become a thing of the past. According to insurers, prior authorization and step therapy are protocols used simply to ensure patients receive the medicines, treatments and thera pies that are the most safe and appropriate given an individual’s condition and circumstance.
In other words, insurers say they are looking out for what’s in the best interest of patients, and prior authori zation and step therapy are the mechanisms that enable that watchful and caring eye.
Patients and providers alike see it differently.
“It’s all about controlling costs,” said S. Bobby Mukkamala, MD, president-elect of the Michigan State Medical Society. “With far too much regularity, insurance companies use prior authorization and step therapy to delay—and sometimes flat out deny—patients from accessing the treatments they’ve been prescribed. And the more expensive a drug or ther apy is, the more likely it is to get caught up in the bureaucratic red tape.”
The stalling tactic may work as a cost-saving measure for insurance com panies in the short term, but not before placing unnecessary administrative and financial burdens on the health care system as a whole—something that isn’t surprising given the rigmarole involved in seeing a prior authorization request through to completion. In the end, everyone—including insurers—pays
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Up to14% of U.S. health care spending goes to administrative costs incurred by private and public insurers, compared with an average of 3 to 10 percent in other developed countries. Burdensome prior authorizations contribute to that disparity.
the price. Up to 14 percent of U.S. health care spending goes to admin istrative costs incurred by private and public insurers, compared with an average of 3 to 10 percent in other developed countries. Burdensome prior authorizations contribute to that unfa vorable disparity.
While each patient, case, and treat ment plan may differ, the general process is always more or less the same. A patient with an illness or health challenge makes an appointment to see their physician. The physician examines the patient and then either diagnoses the problem and prescribes a treatment to address the issue, or orders the additional testing and screening needed to develop a diagno sis and a treatment plan.
From there, things often get complicated.
Insurers regularly require physicians to obtain a prior authorization for any prescribed or ordered medicines, treat ments, and diagnostic procedures before agreeing to cover the costs associated with those measures, and that process is one that can be painstakingly ardu ous. Documentation requirements and procedures differ not only from insurer to insurer, but worse, from product and plan to product and plan, creating an unwieldy bureaucratic minefield. Suc cessfully navigating the myriad of forms,
S. BOBBY MUKKAMALA, MD MSMS PRESIDENT-ELECT
formularies and requirements that come with a prior authorization requires a tre mendous amount of patience, money, and most critically, time.
On average, physicians and their staff average almost two business days each week completing prior authorizations according to a 2018 survey from the American Medical Association. The Henry Ford Health System alone has a full-time staff of 100 employees devoted solely to processing prior authoriza tion request. That all comes at an enormous cost. Prior authorization and step therapy practices’ costs to physician practices are estimated to be around $2,160 to 3,430 per FTE physician with total interactions with insurers cost ing $82,975 annually per physician, resources that could all be better spent on administering patient care.
And as exasperating as prior authori zation can be for providers, the frustration felt by patients caught up in the process is undoubtedly amplified. They face the same struggles in try ing to navigate a maze of insurance company roadblocks while also going without the medicine and treatment they need. Often, the frustration is just too much, with an overwhelming 75 percent of physicians reporting that prior authorization can lead to treat ment abandonment, according to a recent report from the American Med ical Association.
“Unfortunately, it’s not at all uncom mon for patients to walk away from a prescribed treatment plan because of all the hoops they have to first jump through in order to actualize it,” said Doctor Mukkamala. “Navigating prior authorization hurdles is often a time-consuming, confusing, and ulti mately, extremely frustrating undertaking for patients. Faced with all of that, it’s not at all surprising that some just simply give up and opt to forgo the care they need.”
Any decision to abandon care costs respondents reporting that prior everyone—including insurers—in the authorization burdens have increased end. As patients wait for the care they over the last five years. need, conditions worsen, health deteri orates and the cost of care skyrockets. The problem has drawn attention from a wide array of patient advocacy Doctor Mukkamala has seen it play groups around the state, with organiza out firsthand. tions like the Hemophilia Foundation “A few months ago, I diagnosed a of Michigan (HFM)—Michigan’s only patient with tonsil cancer,” he said. nonprofit serving the bleeding disor “Thankfully, at the time of diagno ders community through education, sis, he was an excellent candidate for advocacy and supportive services— curative treatment because his cancer working to highlight and communi was localized and easily treatable with cate the growing need for meaningful radiation following a biopsy. The diag prior authorization reform. nosis was made, and the “Hemophilia and other treatment was lined up in a bleeding disorders are matter of days. But before 94 percent of chronic and complex dis being allowed to proceed, Michigan physicians orders that require lifelong the patient needed a PET report that prior treatment and specialty scan to look for the spread authorization red care to prevent and limit of any cancer. tape causes delays internal bleeding,” said “Getting approval for that in care for their Sarah Procario, advocacy scan took weeks, and in patients. and communications man that time, the patient devel ager for HFM. “Timely oped a lump in his neck. The cancer had access to appropriate therapies is a spread in that three-week period. Now, necessity for patients.” instead of just radiation, my patient would also require chemotherapy. However, with nearly all therapies for bleeding disorders requiring prior “Had the requirements put in place by authorization, timely treatment and SB 612 been in place four months ago care is often out of reach for Michigan’s when I first diagnosed this patient, his roughly 4,000 families living with the current wellbeing and long-term prog condition—a serious problem given nosis would be much better today. Stothe nature of hemophilia. ries like these are not the exception. The delays brought on by prior autho rization have gotten out of control.” “Any delay in care can have a severe impact on their health. Even three days without treatment may result in And there’s ample evidence to support additional doctors’ visits, hospitaliza Doctor Mukkamala’s claim. 94 percent tion, and permanent injury from joint of Michigan physicians report that and muscle bleeds,” said Procario. prior authorization red tape causes delays in care for their patients. And The regular delays are a concern for the problem is only growing more Procario and likely all the patients and pervasive, according to a recent sur families served by work of the Hemo vey from the American Medical Assophilia Foundation of Michigan. ciation, with 88 percent of physician (CONTINUED ON PAGE 18)
88% of physician respondents report that prior authorization burdens have increased over the last five years, according to a recent survey from the American
Medical Association.
SARAH PROCARIO, ADVOCACY AND COMMUNICATIONS MANAGER FOR HFM
Unfortunately, they often do. Accord ing to a recent survey by the AMA, 28 percent of physicians report that prior authorization has resulted in a serious adverse event including hospitalization, permanent disability and even death.
“Susan G. Komen is the world’s largest break cancer organization, funding more break cancer research than any other nonprofit, while providing real-time help to those facing the disease,” said Sarah Hockin, Mission Director at the Susan G. Komen Foundation of Michi gan. “Komen served over 65,000 women and men alone in 2019. They were among the 1.3 million people diagnosed annually with breast cancer. Timely care can be the difference between life and death for many of them.”
Trudy Ender, executive director at the Susan G. Komen Foundation of Michi gan, echoes the sentiment.
“We need to do better for these patients,” said Ender. “I can promise you that diseases like cancer are already stressful enough on their own. Making a patient wait and jump through hoops for a treatment or medicine with the potential to save their life is just sim ply wrong. It should not work that way. Every day—sometimes every hour— really matters.” And what makes prior authorization such a difficult pill to swallow is that it’s almost always all for nothing. 97.5 percent of all first-time prior authoriza tion requests are eventually approved. In other words, insurers are delaying critical access to care for essentially no reason.
Doctor Mukkamala sums the problem up nicely:
That effort has occupied physicians, patients and patient advocate groups—a formal coalition known as Health Can’t Wait—for nearly a year now.
Led by groups like the Michigan State Medical Society, Michigan Academy of Family Physicians, Michigan Society of Hematology & Oncology, Susan G. Komen Michigan, Hemophilia Foun dation of Michigan and dozens of other physician and patient advocacy organizations, the coalition has spent months working to make policymak ers understand the need for reform, and the introduction of Senate Bill 612 late last year is proof that their efforts are starting to bear fruit. Introduced by Senator Curt VanderWall, Chairman of the Senate Health Policy and Human Services commit tee, SB 612 would do a great deal to rein in the devastating effects of prior authorization and “fail-first” proce dures by empowering physicians to override step therapy protocol when appropriate and by implementing new transparency, fairness and clin ical validity requirements to the prior authorization process, ensuring patients throughout the state receive timely coverage decisions, and ulti mately, the care they need.
The legislation requires that insurance companies publish their prior authori zation requirements on their website in an easy-to-find and easy-to-understand fashion. To ensure there is clinical validity baked into the prior authori zation process, the bill establishes that adverse determinations and decisions on appeals must be made by a physi cian in the same specialty as the service being requested, while also requiring insurance company medical directors be licensed to practice medicine.
ANDREW BADE, A 20-YEAR-OLD COLLEGE STUDENT LIVING WITH TYPE 1 DIABETES
Perhaps most importantly, Senate tremendous amount to alleviate those Bill 612 would mandate that urgent worries for me and for countless oth and non-urgent prior authorization ers around the state battling their own requests are acted upon within 24 and diseases and illnesses.” 48 hours respectively, which is what’s fair to Michigan’s patients in need of care. Lawmakers continue debating SB 612. In the meantime, physicians, patients and patient advocates can “SB 612 is just sound pol have an impact by sharing icy,” said Doctor MukkaSenate Bill 612 their personal stories about mala. “The modest reforms would mandate the negative effects of prior it enacts would have an outsized impact on Mich igan’s patients and their health.” That’s the message coalition that urgent and non-urgent prior authorization requests are acted upon within authorization and making their calls for reform heard, both of which are made easy by the Health Can’t Wait coalition. members have been work ing to broadcast since the bill’s introduction, culmi 24 and 48 hours respectively... “There are two ways you can have an immediate impact on our efforts to nating in a series of hearreform prior authorization,” said Doc ings on the legislation earlier this year, tor Mukkamala. “The first is to visit with physicians, patient advocacy rep https://www.healthcantwait.org/shareresentatives and patients themselves your-story and share your personal coming to Lansing to offer testimony in story about the negative impact prior support of Senate Bill 612. authorization has had on you, your Most speaking in support of the bill family members, or your patients. focused their time on sharing personal These stories are powerful and help stories about themselves or patients us communicate to lawmakers and the whose health and wellbeing has suf general public alike just how serious fered as a result of delays brought on this problem is. by prior authorization. “Then contact your lawmakers and www. Andrew Bade, a 20-year-old college healthcantwait.org/take-action and click student living with type 1 diabetes ‘Take Action’ to get started. Sending the spoke before the committee about the letter only takes seconds and lawmakers consistent struggles he faces in trying really do take notice. The voice of every to restock the equipment he regularly constituent really does matter. When uses to monitor and maintain healthy enough people speak up, change can glucose levels. and does happen.”
“I still feel like I can live a relatively normal life when I’m relying on the monitors and delivery devices my doc tors have prescribed,” said Bade. “It’s when I don’t have them that things go downhill. Delays brought on by prior authorization regularly place a tre mendous amount of stress on me and my family. Senate Bill 612 would do a
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