1. 12.8: That’s the percentage of adolescents In the US who experience at least one episode of major depression according to the National Institute of Mental Health. New research shows depression in teens is linked to parents, and when treating it, their parent’s mental health improves as well. As social creatures, treating one member of the family helps the other. Check out this story and study we did related to the impact of sports on parents and their kids. Click here
2. Palliative Outsourcing Avalanche: Several Anthem MCOs now use a vendor called Aspire to provide Palliative support to ‘commercially insured’ patients in the last 12 months of life. A full team is made available – to help the patient, family and to help the physicians in the ‘co-management’ of the patient, either embedded in the medical oncologist’s office, or available for in-home NP visits or via a telehealth system. These programs likely continue to get traction with all types of payers, particularly for cancer patient populations, but likely for others. A question will be how the payment for these vendors evolves and who is credited down the line with reduced hospitalization costs. It would seem, based on the 90%+ of 134 payers we polled about this, that the demand is here for these services for 3 simple reasons – there aren’t enough physicians, disease is complicated, and families want this help.
3. Guidelines Change For Behavioral: If you own or are looking at owning a behavioral health provider – or treat patients with behavioral conditions including Autism - check out MCG care guidelines as several Blue plans tell us they will adopt these to help determine what’s medically necessary. This October, Blue Georgia will start to use these for a number of conditions, including for the diagnosis and treatment of autism.
4. Home Cancer Treatment: BCBS of Illinois and Illinois Cancer Specialists announced their first Oncology Intensive Medical Home Pilot in the State for intensive medical home care. The program started as identifying PPO patients who were being treated by an ICS physician who qualified from receiving chemotherapy or hormone therapy and who had breast, colon, lung, pancreatic, prostrate or any non-Hodgkin’s lymphoma diagnosis. The program intends to enroll 150-200 patients per year.
5. Antibody Tests for Neurologic Diseases: In a small but interesting example of the widening attention and favorable coverage that managed care organizations are giving to understanding the science of our behaviors, Aetna released a policy update this month that now considers antibody tests medically necessary for the diagnosis and treatment of neurologic disorders, as long as a definitive diagnosis remains unclear after history, physical exam and conventional diagnostic studies. To approve these tests, there must be evidence that the patient displays clinical features of the paraneoplastic neurologic disease in question and information to show Aetna that the result of the test will directly impact the treatment being delivered. One of the following antibodies must be suspected: Anti-amphiphysin, Anti-bipolar cells of the retina or anti-Recoverin.
6. Gender Dysphoria Treatment: UnitedHealth Care updated in August its Commercial Medical Policy for Gender Dysphoria Treatment including an updated rationale for why certain treatments or reconstructive procedures are considered cosmetic and not medically necessary. The list has expanded since and has far more detail than the original policy. United relies in part on clinical care guidelines from MCG, formerly Milliman.
7. Opioid Policy Change: Cigna released its Non-Medicare Formulary Change for July 1, 2018 to change opioid coverage determinations for both short acting and long acting opioids. This change doesn’t affect opioid utilizers currently being treated for cancer risks or sickle cell disease, or in hospice. For new opioid utilizers, the first time refill in a total daily dose of 120+ MME will require a prior authorization for coverage of their medications. Cigna says it will make a coverage decision within 24 hours after receiving the providers request.
8. Crohns Starter Pack: Humira’s starter pack treatment for children with Crohns disease now requires pre-authorization from Cigna Health Arizona for a number of its HMO plan members and special needs plans. Humira itself must be pre-approved. Physicians must document past medication history of arthritis.
9. Shortage Poll: 1 of 73 managed care executives in our poll last month say that while they are embracing telehealth they are skeptical and have discussed the idea of allowing medical students to finish education but treat earlier. The idea has been floated by others, including in a recent Washington Post op-ed. There are many issues with this concept, one obvious one is that we have ‘trained PAs and MDs today’ in places like urgent care who mis-diagnose and over or under treat, so allowing medical students into these roles would seem to only exacerbate the issue. But that more insurers are discussing this and engaging policy-makers is compelling for all of us. One idea floated in a meeting I was in out in central PA last year was to pay for medical education in exchange for having students serve in rural areas doing primary care alongside an experienced NP.
10. Extra Point: Race, Gender & A Better Outcome. That’s the ‘working title’ of a study we have going that looks at disparities in healthcare but more so the science behind our healthcare decisions. The early finding: Who treats us matters. Take George Costanza. He was so excited about having insurance coverage for a massage back in a 90s episode of Seinfeld only to become completely anxious when he found out his masseuse was a dude. His neck pain worsened but for all his indiosyncracies, George was on to something. Recent studies prove it: Having a black doctor has led black men to receive more effective care, a Harvard Business Study revealed, and nearly 600,000 heart patients admitted over 2-decades from Florida ERs were less likely to survive if treated by a male doctor (study here). But it’s not necessarily one gender or race over another or that for non-emergency situations you fare better with someone of your own race or gender. My own bride went against a hospital’s advice after ripping up her ankle and chose Dr. Lauren Ganey at a university medical center over the hospital’s all male surgery staff, saying she preferred to have ‘a mom’ who could appreciate her need to get back to running again, but then chose a male physical therapist over a female. My girls all prefer Tyler Stanley, a PA at our pediatrician’s office because he says the word ‘boogies’ a lot. Say this, they seem to take those antibiotics much better when Tyler prescribes them.