1. 24 to 7: No, this is not my prediction for the next Super Bowl score (Patriots over the Giants), but rather the number of people in millions who suffer from Cataracts in the U.S compared to the 7.7 million with diabetic retinopathy. In contrast, 2.7 million suffer from glaucoma, and 2.1 million from age-related macular degeneration. Eye disease prevalence is a national and global health concern that is higher in risk for chronic health conditions, accidents, social withdrawal, and depression.
2. Drug Testing Limits: Regence BCBS, starting in July will only allow payment for specific codes for presumptive and definitive drug testing when up to 15 units are billed per test type per year. Codes G0482 and G0483 will be denied as not medically necessary.
3. Vape Movement: 891 of 1,216 students we polled in our consumer study this month of 9th through 12th graders said they know of or have tried to vape. ‘It’s everywhere – in the locker-room, parking lot, bathrooms, and quietly in the woods after dusk,’ students reported. Of the 320 students who’ve tried it at least once (so about 25%), 196 said their mom or dad works in the healthcare field and, except for only a few dozen, they ‘have no idea’ what I’m doing. This poll is conducted anonymously with student athletes in New England. They participate as subscribers of a column on losing in sports.
4. Docs and Hackers: We attended a monthly meeting of physicians at a Harvard Medical School event this month where doctors brainstorm new ‘app’ ideas and technology solutions with software developers. Highlights here
5. Out of Network Update: Blue Shield of California is changing coverage for non-participating providers in 2018 that increase patient financial responsibility when receiving services from non-participating providers. Its PPO plans will have separate deductibles and out-of-pocket maximums for participating (in-network) providers and non-participating (out-of-network) providers. The deductible and cost-sharing for participating providers will not accrue to the deductible and out-of-pocket maximum for non-participating providers.
6. More Liberal Vein Treatment Policy: There’s an interesting pattern of payers saying they are relaxing or ‘liberalizing’ criteria for certain procedures after determining that ‘they almost always approve’ or ‘have less concerns given utilization patterns.’ One example is a few western US commercial plans who have ‘liberalized’ criteria for sclerotherapy to treat saphenous veins below the knee.
7. Genetic Testing Can You Hear Me: Regardless of a patient’s risk factors, Arizona Blue says that genetic testing screening or counseling for hereditary hearing loss is ineligible for coverage.
8. Cigna’s Collaborative Care: Cigna’s senior medical director for behavioral health acknowledges that insurers don’t have the tools that the public sector has, like waivers and grants, to implement collaborative care models. Currently, says William Lopez, MD, the only payer truly reimbursing for collaborative care codes at any meaningful level is Anthem and their Blue Cross plans. “But I’m not so sure that they are monitoring the proper elements of the Collaborative Care Model…what we’re trying to do is introduce more of this into the private sector.” Click here for the full story.
9. Extra Point: In an ironic twist, a military base and army college has just decided to require prior approval for urgent care in its community in Tennessee, a move some said is designed to ‘weed out the cases that could wait a few days’ or ‘make sure people see their primary doctor first,’ although others here expect the policy will increase hospital ER visits, particularly for those with chronic conditions. I see both sides though I also see this through the lens of our Uncle John, a retired Colonel in the Army, and his wife Nancy, both of whom are struggling these days to juggle the health system – trips to ERs, battles with difficult to treat cancers, surgeries upon surgeries related to complications from their conditions. It is hard thing this end-of-life care, made harder sometimes by policies that can have a way of forcing us to go a few extra steps, but sometimes only make the problems worse by adding stress. Uncle John and I email about once a week – we talk about the kids, Gonzaga basketball, and politics. I enjoy these conversations. But lately I’ve noticed a new tone, more questions about his treatment, more apologies because he was at the hospital for a few nights, more difficulties navigating what doctors say. As we enter Memorial Day Weekend, I guess the point for any of us with healthcare businesses that deal with veterans is to be thinking about how to take away some of this stress and make end of life care less policy, more personal.