Valentine Group Health
Linda M. Raileanu, RN, MM/PA, BSN
President/CEO
Genuine Healthcare Resources, LLC
Background:
Linda M Raileanu is President/CEO of Genuine Healthcare Resources, LLC a patient advocacy and corporate health & wellness firm. She is a Registered Nurse with her masters in management / public administration, concentration in health care policy. Linda has over 24 years of diverse health care experience, spanning the hospital setting, managed care, the pharmaceutical industry, long-term care continuum, home health, and alternative medicine. She is also a certified Geriatric Resource Nurse through Penn State.
Linda and her team assist individuals and organizations with navigating through the complexity of the healthcare system from advocating for employees and caregivers to providing corporate wellness programs, especially given the intense changes coming due to the Healthcare Reform legislation, leadership in this area is critical.
She is also School Board Director of the West Chester Area School District.
Overview:
Guidelines are used in the practice of medicine and help to determine the course of treatment. These guidelines also include drug therapies that are recommended. Insurers use these guidelines to determine what services and medications will be paid for. Although guidelines work for many people, there are those for which usual treatment approaches do not work and alternatives must be used.
Insurers hold fast to these guidelines and according to guest Linda Raileanu, getting the medications needed that do not fall within these guidelines is becoming more difficult, especially for newer drugs, those used to treat patients with rare diseases, or for those where the standard “first line drugs” (those recommended by the guidelines) just do not work. Health insurers use ‘guidelines’ to deny access to medications, even if the medication is shown to be the only one that works. This then requires physicians and families to file appeals to insurers for exceptions, which is a complicated process.
Guidelines are exactly that, guidelines, and need to be used with caution when denying access to needed care.
This show will address the following issues, challenges, stories, solutions
- How applying guidelines is needed for care delivery from the perspectives of: (1) clinical and (2) cost.
- How applying guidelines for making decisions on drug therapies is used by clinicians who are treating you.
- How applying guidelines for making decisions on drug therapies is used by insurers to either endorse the treatment plan or not.
- What constitutes “inappropriately guideline utilization” by insurers and how does this impact access to medications?
- Case stories drawn from Linda Raileanu
3 Key Points:
- Guidelines are needed to achieve patient safety/quality outcomes and clinicians are expected to use these guidelines in their practice.
- Consumers need to know how guidelines are being used to drive their treatment plan.
- If the typical guidelines are not working in your care situation, steps are outlined as to what patients and their families can do if in a situation where clinical guidelines are being questioned by the insurer and the insurer is refusing to pay for the care prescribed by the treatment team.
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