1. 71: Percent of colon cancer cases that appear to be preventable through proper nutrition, 30-minutes of daily exercise, and not smoking or being obese, factors that account for 78% of chronic disease risk.
2. Enter Your Own Clinical Notes: Elaine Benes would have loved this. 15% of physician offices in our poll of 316 groups say they are starting to create a system to allow patients to provide input into their medical records. Elaine was ticked, for you Seinfeld fans, when her doctor fake erased her feedback about her rash. Patients of physicians Georgia and South Carolina, will be able to enter information into a system called OurNotes, which allows both patient and caregiver to enter clinical notes and care plans into the record. It will be interesting to see how this helps the physician practices who are managing MA and Medicaid patients in risk arrangements and how it impacts total cost of care and therapeutic decisions.
3. From Pharmacy To DME: Blue Massachusetts, starting in July, will provide coverage for continuous glucose monitor (CGMs) sensors under the Durable Medical Equipment (DME) benefit. Previously, CGM sensors were covered under pharmacy benefits. The move to DME was made, in part, to ease confusion among members as to coverage requirements for these sensors.
4. Tiered Network: Anthem New Hampshire has updated their tiered hospital network, a trend going on across many states and health plans and eventually, we believe, will move into the outpatient arena). Patients in the Granite State will have a higher out of pocket cost when receiving services at St. Joseph Hospital and Wentworth Douglass Hospital. One takeaway is that investment in hospital services, like technology solutions or clinical staffing, needs to take into account the impact of this tiering on customer volume.
5. Pediatric Partners: Advocate and Northshore health systems have partnered to expand pediatric care in the Chicago area in an effort to increase Northshore’s branding power with parents. The partnership will now include more than 600 pediatricians, pediatric subspecialists and maternal fetal medicine doctors from the two systems. Partnership launches in July.’
6. Tails California, Heads (Up) Carolina: Blue Medicaid in South Carolina is about to undergo post pay reviews of certain procedures or services the physician needs to identify as distinct for payment purposes, such as those billed with modifiers 59, XE, XP, XS and XU)
7. Lab Questions: Questionable lab practices have left 4 hospitals in Blue Arkansas’s out of the network. The hospitals were starting to do lab tests with physicians not affiliated with the hospital. These smaller hospitals get a higher rate than large labs do, basically they don’t perform as many tests; the higher pay helps cover overhead. But when these hospitals started to overbill and do more tests than had been forecasted by the Blue plan, total lab costs whent up. In one facility, lab costs were 50% more than larger labs. A secondary issue is the medical necessity of testing by practitioners. Lab benefit management is a growing area of interest for payers – some, like United, have their own integrated service. The Blues generally don’t.
8. Falling Down: Medication, orthostatic, depression and dehydration issues were to blame for readmissions based on our analysis of 65 patients who fell at home within 2 weeks of discharge from an inpatient rehab stay. Interestingly, 49 of the 65 said they were depressed (based on EMR documented notes with an occupational therapist who had visited the home).
9. Combo Therapy: Avenues to avert misuse of amphetamines have become an area of interest for researchers. One potential option is prescribing a combination of methylphenidate (Ritalin, Concerta) and naltrexone (Vivitrol), a drug commonly used to treat alcohol and opioid abuse. Story here
10. Extra Point: Connor Murphy ‘disappeared’ but he didn’t leave the stage when Janine, me and the girls saw the Broadway show Dear Evan Hansen this weekend. The character’s suicide was the backdrop for a gut-wrenching show about growth and honesty and managing our behaviors. I cried through most of the first act, so much so my peanut M&Ms weren’t as crunchy delicious as usual. I felt more connected as many of us would to the parents than the teens. I thought about my kids. And I suppose I found it interesting that Hansen’s growth actually started when he began to avoid taking his anxiety medications and trusting his instincts for helping others. My younger daughters were confused about Murphy’s death – not just the idea of taking one’s life – but that he never really left the stage. ‘I wasn’t sure,’ Sophie said, ‘because he was in a lot of the scenes talking, singing, dancing – even smiling.’ For a lot of us who operate healthcare businesses or manage the cost of healthcare there’s an underlying message to this musical – that it remains very difficult to see, understand and prevent these tragedies and takes even longer to help those affected by them. ‘There’s a cost I don’t think we think about with suicides,’ says Peggy Flarentine, RN, ‘it’s the families and the close friends who struggle to grieve and don’t get the services they need, and end up with their own challenges, addictions.’ Both payers and providers acknowledge that there is an opportunity to better manage mental health but I do think the underappreciated opportunity doesn’t lie necessarily with the counselors and treatment programs but rather with everyone else – caregivers, families, coaches, schools, primary care, and hospitals. ‘Can you see this coming and have a way to prevent it – that’s the ultimate value based care if you think about it,’ says Flarentine.