1. 380,000: The number of premature births a year or about 10% of the US births, according to a Cigna source we interviewed who says the managed care plan is improving coverage and reimbursement for ultrasonagraphy in the first trimester, particularly for those women unclear about the timing of their menstrual cycle.
2. AIM Higher, Radiation: In 2019, new approval rules will take effect for radiation oncology, and most ease some of the existing requirements, which would be a plus for providers in states where Anthem is the major payer. AIM, the Anthem company that determines clinical appropriateness and site of care for services including cancer treatment, will remove age and tumor size criteria for determining the appropriateness of treatment of accelerated whole breast irradiation, no longer limit treatment with IMRT for rectal adenocarcinoma and will add criteria to allow for IMRT for head and neck lymphomas.
3. What’s Your Place MAT? If you’re in the world of addiction treatment, including medication assisted treatment, there’s a new ‘ranking’ coming out that will place some centers ahead of others on the wish list of payers. The BCBS Association is going to be using ShatterProof to help create centers of distinction for opioid addiction treatment, and eventually for various behavioral health conditions that can benefit from promoting centers of excellence.
4. United will use Optum Fertility Solutions to start doing clinical coverage reviews for a host of infertility treatments. This is kicking off this month. Drugs impacted include Bravelle, Follistim, Gonal and Menopur. The reviews will apply to patients on plans with outpatient prescription drug coverage through the pharmacy benefit for injectable infertility medications.
5. Perfusion: Starting in December, Aetna won’t pay for perfusionist services when billed by an agency or individual. Perfusionists, who help manage a patient’s physiological status during cardiac and cardiopulmonary procedures, must look to the hospital for reimbursement, both for inpatients and outpatients. The MCO will pay the hospital for the technicians responsible for assembly and operation of pumps with an oxygenator or heat exchanger.
6. Rickets Check: In November, Aetna will join the bandwagon and put criteria in place for both a drug’s medical necessity, and the site of its administration. The most recent pharma agent to require this two-prong pre-approval is Crysvita, the first treatment for a rare inherited form of Rickets. The FDA approved it in the spring.
7. Extra Point: My daughter tries out today for the spring musical and hopes to eventually tour around cities like Chicago and Paris to, in her words, ‘get a little culture dad.’ She can act, sing and dance and has great pitch and stage presence for a teen. But like a lot of us, I see the time with her changing. No longer are the days when she would sing countless renditions of Part of My World then share a black and white cookie. But there may be a way to prolong things. In a surprising and bold move, a health insurance company has started a playhouse. George Street, the brainchild of Horizon BlueCross BlueShield, is touring schools nationally with a show about the challenges of addiction. Other shows, even musicals are ‘likely’ says a source and the insurer is hoping to use the format to reach a new audience about tough issues. It’s prevention and innovative and a new page for the usual tepid reactive strategies of insurers to address crisis and cost. And, who knows, maybe Soph’s next audition will land her a role touring with Horizon’s George Street company, and she and I can practice her lines and split a black and white cookie on Amtrak’s caboose.
Save the Date: Friday, November 2nd and 16th, Managed Care Friday Forum