1. 60: That’s the percentage of people suffering from Alzheimer’s who are women. Recent studies show women endure Alzheimer’s disease more than men. For years it was written off as an age issue because women live longer than men. Now, neurologists are studying that it could be for more reasons than just life expectancy. Read the full story on the Kaiser Permanente studyhere.
2. Asthma City: Asthma Capitals and the Asthma and Allergy Foundation of America (AAFA) released research on the “Most Challenging places to live with Asthma” including Springfield, MA, Richmond, VA and Dayton, OH. New York ranked Number 20th and the city with the highest estimated asthma prevalence is Louisville, KY. Asthma causes 2 million visits to emergency rooms each year and each visit averages in $1,502 in cost. Total per member per year costs for asthma decreased by more than $500 due to a local Medicaid plan’s program. Poorly controlled asthma is very prevalent in the Medicaid population but asthma exacerbations are potentially preventable. ‘PCPs lack timely data and outcomes depend on an appropriate system of care,’ says Barry Lachman, MD, who is Parkland’s Community Health Plan medical director. The Medicaid MCO developed a predictive model, care coordination system and EHR alerts for asthma patients, and the results were significant: Asthma related ED visit rates decreased by 30% (from 16% to 11%), hospitalization rates by 43% (from 3.44% to 1.97%), and total costs by 40% (from $1285 to $766 per member per year). The asthma medication ratio increased by 15%, from 0.39 to 0.45. Results to be presented in an upcoming discussion on asthma.
3. United Giveth and Taketh Away: United Healthcare has made 3 interesting payment adjustments – certain outpatient injectable drugs for cancer patients will require pre-approval starting in November, including chemo drugs with a Q-code, colony-stimulating factors like Neulasta or Neupogen, as well as Xgeva and Prolia. Medicaid patients in 4 states are impacted (Rhode Island, New Mexico, Iowa and Nebraska). OBGYN groups will get paid less for c-section deliveries if the documentation doesn’t have the right diagnosis, coding or documentation. On the plus side, United will no longer require medical records to be submitted when reporting both an evaluation and management service along with a radiologist’s interpretation.
4. Cost Share Hike: Aetna’s Kansas City metro area HMO has increased cost sharing for home infusion to 25-30% of the plan allowance in two of its benefit plans, and added cost sharing for professional mental health and substance abuse services, outpatient services including ABA, and skilled behavioral health services.
5. Tiered Network: For those of you operating specialty practices the movement to tier-based reimbursement continues as BCBS of North Carolina is the latest to create a tiered network. The plan has 2 tiers: Tier 1 providers get better rates based on varying clinical quality and cost measures, such as orthopedic physicians conducting imaging 28 days after a patient’s initial evaluation for low back pain or endocrinology groups prescribing a lipid-lowering therapy to adults who have a diagnosis of hyperlipidemia and CAD but without diabetes). Gastroenterologists, neurologists, cardiologists and OBGYNs are included too. Reach out if you’re interested in discussing the scoring methodology used by the plan as it is in some ways a roadmap to success in the new value-based world.
6. The End of Prior Authorization: Think about it – a world without pre-authorization and less concern about how your physicians document. As predicted here, there continues to be signs of more progressive payers seeing the benefit of unleashing successful health systems and physician groups by taking shared risk with them to manage a population minus all the administrative redtape. We’ve long since discussed here the idea that your companies need to think not just in terms of how to negotiate higher reimbursement rates but how to become the defacto benefit manager for health plans – evaluating what’s needed and making treatment decisions without worrying about the economics. Therapy companies too – PTs and behavioral businesses – have an opportunity here Patrick Conway, MD, president of BCBS of North Carolina, recently told a health informatics convention that the goal ought to be to get the provider and payer unlocked from rigid rules and that perhaps we ought to ‘turn off all prior authorization’ and, other than risk coding and STARS measure reporting, worry less about documentation.
7. Therapy in a Box: Subscription boxes are all the rage these days. Therapists have come together to produce “TheraBox: Ingredients to Happiness,” a monthly subscription box filled with items designed with the patient in mind. Each box is curated by therapists and includes a happiness activity inspired by neuroscience and positive psychology research and includes full-sized wellness items shipped to a doorstep.
8. Tech App for Therapy: A new therapy app as is on the market and no it’s not Talkspace. BetterHelp is its competitor as the largest online counseling platform worldwide. Whether by phone, text or video, patients have access to professional counseling 24/7. These counselors are licensed, trained, and accredited psychologists, marriage and family therapists, and clinical social workers. Health insurance coverage can be very limited but there are signs of interest in these models from the managed care community, such as behavioral network New Directions. Financial Aid can be applied in some situations.
9. Extra Point: A great white swam by us Tuesday at Head of the Meadow beach in Cape Cod. I pulled a George Costanza, toppling over little kids and grandparents enroute to safety. Thankfully the great white didn’t get anybody and no one (except maybe God above) saw my cowardice. My oldest kids, Jack and Mukue, sprinted along the water’s edge chasing the shark. Jaws was maybe 35 feet from the coastline at this point, eventually disappearing into darker waters. 45 minutes later the beach guards put up a green flag alerting us that we could go swimming again. My kids, and the couple hundred other beachgoers, ran into the water without much fear. A humid day will do that, though it is bewildering that people have so much faith in the lifeguard system and their own ability to get out of the water before Jaws bites. I will say that the generation that grew up watching Quinn get eaten off the shores of Amityville seemed a bit more cautious. But, look, if you read the science about sharks, our collective fascination with these ocean giants isn’t all that misguided. Healthcare researchers say shark cartilage can be used to treat cancer, arthritis, psoriasis, diabetes, and in healing wounds. Amazing to think about the possibilities – but I’ll be honest, I’m still going to forever hear the Jaws theme.