1. 65 Seconds: Amount of time it takes for someone new in the U.S. to develop Alzheimer’s disease – which by 2050 is expected to shrink to one person every 33 seconds. 5.7 million Americans are living with it now and depending on which state you live in, assisted or senior living can cost approximately $2,525 to $5,745 a month. My grandmother, who spent her childhood in the mountains near Napoli, spent her last 12 years in Fairlawn New Jersey with the disease. I lived with her for part of that time – she was only in a SNF near the end, when pneumonia got her. The pipeline of drugs to address the disease have hit roadblocks recently – Pfizer most recently ending its R&D for neurological conditions. Solutions in the interim seem more focused on care management models, like BCBS of Massachusetts transitions in care model. ‘I’m not sure we have any alternatives – these patients need to be managed at home,’ says Pam O’Hare, a Blue case worker who works with vendors and transition teams. Payment for these services will likely evolve into PMPM and even global capitated arrangements.
2. Dermatology Utilization Boost: Pre approval from United Healthcare is no longer necessary for excisions of malignant lesions, billed using code 11606, starting in April. Most of United’s commercial plans will adopt this policy, but Oxford plans won’t.
3. Wigs after Chemo Coverage: Kaiser Permanente of Oregon added coverage for wigs limited to 1 synthetic-haired wig per year following chemotherapy or radiation therapy. The wigs are considered “outpatient durable medical equipment” as a part of their Senior Advantage plan. Wigs covered by health insurers isn’t a new thing. BreastCancer.org claims that most health insurance companies cover part or all of the cost of the wig if a doctor writes a prescription for an “extra-cranial prosthesis.”
4. Separate Payment No More, Separate Ways Forever: I wore a Separate Ways t-shirt to school for nearly 30 days straight in 6th grade, just so my classmates knew that it was the best Journey song. But being separate isn’t so good for supplies these days. Syringes, catheters, parenteral infusion pumps and other equipment used in various procedures and settings are no longer separately reimbursable by Aetna as of next month, under a new payment policy in which it says items like these are ‘part of the overall episode.’
5. Lab Test Network Rule Change: Molina Healthcare of Ohio updated its laboratory testing payment policy. Providers are now required, as of February this year, to submit specific laboratory specimens to in-network clinical labs. This ensures laboratory services are provided by a credentialed laboratory, and that Molina Healthcare has access to laboratory data needed to measure HEDIS performance quality and outcomes for all network providers.
6. Palliative Partner: Empire Blue in NY will partner with Aspire Health starting this spring to help commercial patients suffering from advanced illnesses. Aspire provides telephonic and home visits, but doesn’t replace the PCP network, although a source with Empire told us, ‘Look, the PCPs are too busy and not managing these patients – so while this doesn’t replace the doctor, at some point I think these companies will just add medical directors’
7. Imaging Heart Update: As evidence that payers usually react within a few months to major guideline changes, specialty benefit manager AIM will incorporate recent literature findings about the use of coronary CT angiography and fraction flow reserve as the first-line test to be used in patients with suspected coronary artery disease. AIM, which serves many health insurers, will update its pre-approval requirements as of May 1st to reflect this.
8. Multiple Procedures Less: Aetna, in March, has started to reduce payments for multiple procedures performed on the same patient on the same day. Therapy services (50% less), diagnostic ophthalmology (20)% and diagnostic cardiology (25%). Both of the diagnostic reduction only apply to technical services, not physician interpretations.
9. Asthma, Growth Hormones Rx: As of March 1st, a number of health plans have begun to require pre-approval on all growth hormone products. Blue Michigan says it has different requirements for pediatric members and adult members. Its Blue Care Network also no longer covers the asthma medication Alvesco starting this month. They are suggesting lower-cost alternatives including Arnulty, Flovent and Ovar.
10. LGBTQ Suicide Prevention: LGBTQ individuals are almost 3 times more likely than others to experience a mental health condition such as major depression or generalized anxiety disorder. For those of you working in the mental health field, or in hospital or primary care settings, there are opportunities to better address these risks to prevent hospitalization or worse. Click here for the story.
11. Extra Point: A dad in Virginia made his 10-year-old run to school in the rain because the kid’s bus driver suspended the boy from riding the bus for bullying kids. The dad drove his truck behind his son en route to school. He says it hopes to teach the child a lesson. A lot of folks found the dad’s online posting of the incident a bit uncomfortable. That aside, the point he makes – healthy punishment and being a parent - makes a lot of sense. Of course I want my kids to run and play because it’s good for them, not as punishment, but I’m not looking to argue with the dad. Like a lot of us, he’s just trying to do his best. In our poll of 452 parents this week, 79% said they drive their kid to school, often less than the 1 mile this boy had to run, and often in silence, if you discount the sweet sounds of texting.