1) 425: Dollars that several surgeons told us they are charging Anthem patients upfront before cataract surgery to cover anesthesia services since the insurer no longer considers anesthesiologists or nurse anesthetists medically necessary for administering and monitoring sedation during the eye procedures. Kids under 18 aren’t impacted but adults are and one practice here in my state told us the policy has changed patient behavior – in some cases the patient flat out refuses and leaves rather than doing the procedure, others ‘have got wind of the charge’ and ‘cancelled’ the procedure, ‘telling us they will find another option.’ One Midwest practice took a different approach, not charging anything—‘we have picked up about 10-15 new patients simply because they didn’t want to pay their ophthalmologist’s fee for this.’ In an odd way, the payer’s policy--or rather the provider and patient reaction to it--are an interesting example of the science behind our behaviors, how in some cases our initial reaction is to react without understanding bigger picture, while in other cases we slow down and see the opportunity amid the chaos. Contact us for full details.
2) The New Bundle: There are some interesting similarities and differences among commercial payers in their approach to bundling payment for maternity, including a new concept that will ultimately reward practices for mental health management before and after birth. Horizon BCBS in New Jersey now has an episodic program with 300 practice sites. The MCO contracts primarily with physicians and uses a retrospective, upside risk-only payment. Participating practices get a per-patient budget determined by 2 years of their historical data. Humana’s model is different—it’s retrospective and will be triggered upon admission to the hospital for labor/delivery. Bundled services include all prenatal visits during a 200-day period prior to the birth, the delivery and then 45 days after discharge. Quality measures your businesses would think about include uncomplicated C-section rates, preterm birth rates and C-section rates. Other payers are moving into more 2-way risk, and some, like Parkland Health Plan in Dallas, are thinking of quality measures in more unique ways by trying to incent more preventive screenings for depression to reduce the risk pre-term birth and address post partum.
3) In 5 Years: If you own a healthcare provider practice, or serve one with various software or technology solutions, keep in mind that within 5 years – by let’s say 2023 – a larger portion of the commercial payers in the US will own, operate and leverage their own medical groups. That’s at least according to 74 commercial payer strategy officers out of 112 we polled last week who said they are interested in local market models where they could ‘own the medical group’ and ‘steer patients to the group’ using copay incentives or other tactics to incent patients to use these groups, and then ‘gain control over the entire flow of patient care when they need higher level services, like pain management or surgery’. Finding whether you are a winner or loser in this depends a lot on existing market share, affiliations, access and the overall productivity of your groups, says Martin Saunders, MD, who is leading a strategy by a regional payer to ‘pick 2-3’ target groups per market to explore for acquisition and alignment. ‘I think our focus,’ Saunders said, ‘will be similar to the way a self-insured plan would do it – pick a place for certain orthopedic procedures and have the local physician groups and the PTs all aligned so that the cost is clear and predictable, ‘and so too is the outcome’. I asked Saunders about ankle surgery, given my wife needs this next week, and he said the goal there would be to ‘identify the sub-specialists’ and make sure the ‘hospital ERs who triage the cases and reset the ankles’ are incented to refer to the best doctors, rather than just those in their system. ‘This is probably not possible to control but we are thinking through ways to do it’
4) ADHD Combo: Mark Stein, who heads the ADHD and Related Disorder Clinic at Seattle Children’s Hospital, said that the combination therapy could be a “promising approach to make the effects of methylphenidate more specific and personalized to adults with ADHD,” which he described as a population in which there are concerns of stimulant-related euphoria developing into abuse. The combination, however, would not be useful for children, since this age group more commonly reports dysphoria when taking ADHD-related amphetamines. The next step, according to Stein, would be identifying how effective the combination therapy is in groups who are at risk of SUD. Story here
5) Scrubs: The number of new psychiatry residents grew more than 5% from 2010 to 2015, a somewhat encouraging trend given access issues to mental health professionals in places like Alabama, where there’s really only 1 mental health professional for every 1,260 people, according to the Suicide Prevention Center. Center. In our poll of health plan ‘strategy’ officers this month, 38% named mental health as their #1 emerging priority but only 4% said they had a good solution and would look to providers to create programs and models. ‘I think we can encourage screening and tinker with payment and networks, but at the end of the day the provider community has to figure this out’ said Nicole Wiley, a strategic advisor for Blue plan in the Midwest.
6) Extra Point: In one of my first jobs as a reporter in the late 90s I wrote an investigative piece about a retail store in Swampscott Massachusetts selling fake Kate Spade hand-bags. A quote from the FCC about the illegal practice was the key to my piece and eventually got the store in trouble. I felt bad. Here I was a 23-year-old using words to hurt a long-time mom and pop shop. What did I know about the struggles of running a retail shop? Months later, after several not-so-nice letters to the paper about my story, I got a nice letter from the Kate Spade company to make up for it. Mental illness took Spade’s life this week. It took CNN personality Anthony Boardain’s last night. Boardain, who admitted to years struggling with substance abuse, is a success story. My wife and I enjoyed his ‘Parts Unknown’ voyages. He had this endearing penchant for curiosity. There are tens of thousands likely not as famous as these two icons who struggle right now with mental illness. If I were a healthcare business owner, one question I’d be asking is how curious your physicians and nurses and PAs are about this. How aggressive are they in finding the illness and triaging or treating it before it ends up on TV. Mental health identification and management is an often missing component of bundled/episodic payment models and yet it seems to be a central factor impacting outcomes.