1. One Million: Number of people over 5 years of age that are considered functionally deaf. More than half of those people are over the age of 65. With the great popularity of the ear buds and beat headphones at the gym, hearing loss is becoming more of an issue. Letting your kids playing video games at full volume can be more damaging to their hearing than you think. A recent study involving participants aged 18-41 shows those who showed small amounts of hearing loss had unusual activity in their right frontal cortex of their brain. The study concluded these changes show signs of dementia later in life.
2. Dementia Guidelines: The Gerontological Society of America has developed them. Read the full list of recommendations here.
3. Behavioral Guidelines: Starting in October, Blue Georgia is among the health plans who will start using MCG’s clinical guidelines for coverage of behavioral services including autism screening and in-home services.
4. GI Technology Impact: Cologuard has gotten a boost lately with full coverage decisions in place – or about to be, including no copay for the patient and no pre approval requirement for the physician.
5. PA Lifted For Psych Testing: BCBS of Illinois no longer will require pre approval for psych and neuropsych testing for its Medicaid and Medicare members starting this summer, as long as the provider ordering the test is part of the payer’s network. The exception is if BCBS determines a provider’s testing varies a lot from peer groups. Periodic auditing will also be done to ensure medical necessity.
6. Diabetes Monitoring: Asked for the features of remote monitoring systems that would be particularly valuable under more risk-based and bundled payment models, 79% of endocrinologists suggest "stickless" monitoring for glucose without the use of continuous glucose monitoring by subcutaneous needle, while 54% want blood sugar monitors to be able to enter diet and automatically upload blood sugar levels so the doctors can make ‘more real time adjustments’ may be made’. Endocrinologists received modest reimbursement increases from a number of health plans in 2018, mostly for sharing data with the health plan on a number of measures, including one where the health plan encourages longer sessions with patients to ‘head off’ adherence risks. Our story on endocrinologists and monitoring by clicking here.
7. ABA Owners: They may want to take a cue from a memo one Blue plan in the south sent to therapists there, acknowledging that ‘evidence that supports ABA continues to be limited because of wide variations in method, findings and philosophical bias,’ which BCBS of Tennessee medical directors say makes conclusions about coverage difficult. That the broader market considers ABA standard of care for autism is one thing; health plans will continue to play the role of skeptic and manage the benefit tightly.
8. Pathology All In: Blue Tennessee has adjusted payment for anatomic pathology at facilities and, starting in 2019, will pay facilities an ‘all inclusive rate’ for inpatient and outpatient services, including pay for services and supplies. There may be contractual exceptions. The facility payment includes the technical component for professional services provided while a patient is in a facility setting. The policy applies regardless of the relationship between the pathologist and the facility (e.g. the hospital).
9. Readmission Policy Change: 32 plans out of 68 polled recently on readmissions said that if an inpatient service claim is fully denied for a Medicare Advantage patient who is readmitted to a hospital within 48 hours of an acute hospital discharge, then any associated professional (e.g. physician) service claims will also be denied.
10. Extra Point: Perhaps coincidence but in a summer when my wife broke her ankle ala Gordon Hayward, my son had his second bout with multi-directional instability in his shoulder and a cast on his wrist, and my daughter had a hard-to-diagnosis hip issue common to refugees from Thailand, orthopedics has jumped to the #1 spot in both the Managed Care Index of health plan priorities, and the top service line of focus among hospitals. We have so many bands and boots, band-Aides and braces in our hallway-turned-mudroom that I thought about selling some of them on Amazon. Turns out Amazon had the same thought. As of this this fall, they are in pilot programs with a couple of major hospitals, including UPMC and Seattle Providence Health, whereby doctors recommend bundles of medical products to their patients before they're sent home and have those products delivered to patients' homes at discharge.