1. 6157: The name of a Senate bill in Washington state that forced Regence BCBS to do away with a policy requiring pre-approval for PT, chiropractic, massage, OT and speech therapy for the first 6 visits after an initial evaluation. A source with Evicore, which handles these requests for the insurer, told us it will identify patients who won’t need the authorization in this state. Pre-approval is required for visits after 7 and, due to the policy, an Evicore therapy evaluator said, ‘this sort of makes it harder to get approval for more than 3-5’ unless it’s a youth injury situation or a patient coming off of a surgery. ‘The chronic cases will be lucky to get 1 or 2 more at a time, we will need to see a lot of evidence, notes’
2. Tiered Network, By Specialty: North Carolina’s Blue plan uses administrative claims data to tier providers into 2 groups based on their cost and quality, using specific metrics for each specialty, like cervical cancer screening for OBGYNs and imaging studies done more than 28 days after initial visit for low back pain for orthopedics. Other specialties included are cardiology, endocrinology, GI, neurology and general surgery. See the metrics by specialty by clicking here.
3. Homeward Bound Addiction: Anthem New Hampshire has added a home-based addiction treatment provider to its network cut from the VNA model where addiction nurses and psychiatrists, recovery specialists and therapists team to treat patients at a lower cost for longer periods or help payers more rapidly and safely transition patients out of residential or inpatient settings. According to our poll of 136 families nationally this past quarter whose son, daughter or relative has suffered from a substance use addiction, 57%, up from 49% in an earlier poll, said their family member has been in treatment more than 4 times and 73% said they have been treated at least twice in a residential program. The program initially has had success in Connecticut.
4. Shoulders, Hips, Knees & Toes: Boeing, Walmart and others are among the narrow network pioneers, putting out RFPs to let hospitals ‘compete for our business’ and include ‘free primary care’ without copays and deductibles or offer an exclusive on all major surgeries. It’s narrow and limited choice, ‘but people don’t care’ says a Home Depot HR manager Suzie Nicols – ‘they want it to be easy.’ 77% of 50 large self insured plan directors in our poll this fall, up from 63% last year, are opting for more of a ‘procedure driven’ approach, selecting specific hospitals or centers for knee procedures, for instance, and ‘paying full travel to send patients and a caregiver, if needed.’ Next on the horizon by 2020, although I suspect sooner, will be exclusive national contracts for substance abuse or behavioral health centers with insurers who manage the ‘healthy/younger millennials – like age 21 to 34’. ‘Makes sense to have 1 contract, agree on a single rate, fly patients, and give the provider risk,’ says Sal Gentile, chief executive of a soon-to-be startup ‘millenial’ focused insurer called Melody.
5. Up in The Air No More: Newman once said that Zip Codes, well, ‘they are meaningless,’ a funny line from Seinfeld that made you wonder if the mailman was on to something. Well, BCBS of Tennessee doesn’t think so. Starting in January, the plan will require pick-up and drop-off zip codes, plus mileage and a host of other details from air ambulance providers. Air transport companies must get pre-approval, starting in 2018, for any so-called non-emergent transports, basically anything other than from the scene of an accident when ground transport may pose a threat. The billing rule changes are a small step to help the plan manage the high cost of out of network. This same plan has instituted a max pricing policy that gives contracted providers a rate 5x Medicare rates and others out of the network 3x Medicare—both substantially lower than the typical charges, which in recent years have been around 10x Medicare. In 2016, more than 2,000 BlueCross members received air transport as part of their care in Tennessee. ‘We paid more than $50 million for those services, which reflects a 73% increase from just three years ago (29m),’ a source for BCBS of Tennessee reports. About half of payments were for non-emergent situations, one in which the plan paid more than 450k for a fixed wing transport for a patient coming from Arizona back home and $25k for a patient being transferred between hospitals just 2 miles apart. Details on the results of the plan’s strategy to increase rotary and fixed wing contracts will be discussed in an interview in a couple weeks.
6. Cigna’s Opioid Change: Cigna made changes to their drug formulary list effective July 1, 2018, for non-Medicare customers filling an opioid prescription for the first time in a total daily dose of 120+ MME will require a prior authorization for coverage of their medications. A decision will be made within 24 hours after receiving the provider’s request. This change does not affect opioid utilizers currently being treated for cancer or sickle cell disease or in hospice.
7. Women’s Health: The demand for Women’s health services is on the rise 6% by 2020 says the US National Library of Medicine and National Institute of Health. They estimate 81% of OB-GYN related services will be for women of reproductive age (18-44 years old). This growth will translate to a need for physicians or non-physician clinicians which is equivalent to 2,090 full time ob-gyns. This will require a larger provider workforce. Read the study here.
8. Dakota: North Dakota was the 39th state admitted to the union and became the 48th to require autism insurance coverage for all state-regulated plans that have mental health coverage. The law prohibits caps and limitations on other coverage including speech therapy, occupational therapy, and physical therapy. Grandfathered plans are required to include the coverage as of October 1, 2018, and non-grandfathered plans are required to include coverage as of January 1, 2019. A school administrator in the state capitol, Bismark, said this will help meet a backlog of more than 700 kids in her district needing services. ‘We haven’t been able to handle it and parents have been at a loss, juggling on their own’, Peg Florence said.
9. Therapy Pups Help In Behavioral Crisis: College students experiencing both anxiety and depression is one the rise, 52% citing psych related needs up from 44% according to a survey of college counseling centers. One way universities are helping their students is through therapy dogs. Our own Erin O’Donnell interviewed the President of the Alliance of Therapy dogs. Read full story here.
10. Extra Point: On August 4th and 5th I’ll be traipsing through southeastern Massachusetts on a road bike for the Pan-Mass Challenge, a fundraiser for Dana Farber and The Jimmy Fund. I took the Trek out of the garage last weekend. My 10-year-old thinks it’s too tall and needs stickers and some “puffed handle cushioners,” whatever those are. But what does he know anyway? I admired it for a whole day until my wife said, “You going to ride it sometime or just let it collect dust?” The Trek represents opportunity, for peace from screaming kids and poop stains, a sort of flashback to those days riding the Huffy in the backwoods by Archie Lane. Riding a bike is now an Rx too, as an increasing number of PCPs are encouraging adults and seniors to get a bike and ride to address hypertension among other risks. To read my essay about one of my first Pan Mass rides in 2012, click here