1. 511: In our poll of 511 primary care providers with board certification in geriatric medicine, a startling 84%, up slightly from last year, said that physical therapy services for seniors are likely unnecessary or at least need deeper evaluation to determine whether the patient has other comorbidities or causes of pain, such as substance abuse, dehydration, untreated PTSD or depression, or a sedentary lifestyle.
2. GI Bundle, With A Twist: A health plan in the east has created an episodic payment model for those treating Crohn’s disease. Payment includes behavioral health treatment for those with depression or anxiety stemming from the disease. 50 patients were involved in the initial pilot at the Digestive Healthcare Center in New Jersey. The payer, Horizon Blue, pays them a fee for service, then shares savings with the group after a year of service based on the group’s quality metrics performance. If I’m reading this, part of the story here is not just about how to pay and incent good care but it’s a roadmap for the group practices of the future – those who can integrate the right specialists and services to manage the cost ‘in the clinic’ setting rather than rely on others. In a quick poll of GI doctors, 31 of 43 said they would or have entertained the idea of bringing in a therapist as part of the practice offering to help patients deal with the mental health effects of their conditions. This model, and the inclusion of behavioral treatment in the episode, is somewhat similar to Horizon’s payment structure for maternity and post-partum.
3. Hip & Knee 10% Cut Goal: Blue Michigan is looking to save 10% on total joint replacement costs that can go up to $55,000, kicking off an episodic payment that goes for 90 days after surgery, says Steve Anderson, who heads up contracting and networks. 64 orthopedic surgeons will be part of the program’s initial roll out, spanning 7 health systems and 9 counties; they represent about 1 in 3 surgeries today. Both HMO and PPO patients needing total hip and knee surgery will be involved. One of the goals of the program is to reduce variation in costs and outcomes and encourage ‘at-home’ rehab if it can work for the patient, vs. facility based.
4. Radiation Oncology Middle Man: Blue Kansas, starting in January, will require HMO, EPO and PPO patients in its plan to get pre-approval from EviCore for oncology and radiation therapy.
5. Dermatology Drug Refund: Regence BCBS is asking for refunds for a drug they overpaid. The drug, Ameluz, is prescribed by dermatologists often and used to treat mild to moderate keratosis. It was initially reimbursed using standard rules for drugs covered under the medical benefit. The health plan paid for it based on a complicated calculation related to the drug’s strength. A Regence spokesman said they ‘originally calculated’ reimbursement using ’20 billing units per tube based on the drug’s strength but ‘we found out that CMS calculates 200 billing units per tube based on the weight of the tube, not the strength of the drug.’ The code for this drug, HCPCS J7345, corresponds to the number of units of service in a single 2gm tube but CMS’s Part B average sales price fee schedule doesn’t include any billing unit per package information for Amelux, Regence said. The new reimbursement level will be retroactive to the beginning of this year.
6. Puzzle Pieces: If you’re like me, puzzles are a great way to work a different part of your brain but boy are they frustrating, particularly when your kids use pieces for their Halloween costumes. For addiction treatment, health insurers are finding it similarly frustrating – they don’t have all the data and evidence. ‘We don’t have all the puzzle pieces to say what’s good care,” Jennifer Atkins, a VP for network development with the BCBS Association, told us at the Payer Behavioral Summitt late last month. She says the organization is working with Shatterproof around finding the best centers of distinction for medication assistance therapy, as well as filling the gap in evidence based care for treatment. A multi-year pilot using a quality rating system is going on to help with determining the best centers and the best way to pay for treatment. Other payers, like United, are also working with Shatterproof, a spokesman said.
7. Overdose Help: Narcan®' and naloxone, two common drugs for treating a narcotic overdose, will be available at no cost to BCBS Massachusetts members under a new pharmacy benefit for all of its ASC accounts starting in January.
8. Billing Attention In PA: Independence Blue Cross says it is adding a host of procedures to ensure physicians bill correctly. They will hone in on several modifier codes (26, 77, 59 and 78, as well as coding for services done during a global surgery period and use of ‘add-on’ codes. These will be denied or returned to be corrected.
9. App Frenzy: Beginning January, Happify and iPrevail will be available as part of Cigna’s Total Behavioral Health® program, a comprehensive suite of solutions offered to employers to support the health and well-being of their workforce.
10. Infusion Site of Care Changes: Since October, nurse reviewers for 2 national MCOs have started to work with patients needing specialty pharmacy infusions to determine the appropriate setting for the infusion – home, infusion center, physician office or, if necessary, the hospital. ‘We believe that there’s a problem on both sides – underuse of the low-cost home setting and possibly underuse of hospital infusions in some cases when the physicians perhaps overlook patient factors or safety factors. The case manager serves as independent check to protect the patient and make the best use of home infusion’, Barb Taylor, RN, a nurse reviewer told us. Taylor says that out of the last 10 reviews she’s done, she changed 6 of them, three to home infusion (when the patient was unaware of this option), two to the infusion center for IVIG (due to patient concerns about having the procedure in the physician office), and one to the hospital.
11. The Relapse Cycle: In our poll of 90 parents from our consumer panel whose kids have suffered from substance abuse and been in treatment at least once, 71% said their kids didn’t go to treatment initially because the program took too long to get approval for treatment from an insurer, and in an estimated 85% of those situations, the kid relapsed and was eventually hospitalized. ‘The window is short. That was the case for our son,’ said Angela Filler, 57, of Oklahoma. ‘There has to be a better system to get these kids into programs that work’
12. Risk Contracting Commission: 13 of 20 health plans we polled in April said they have recently created ‘risk contracting’ teams and directors of contracting expressly responsible for studying options for risk contracting (upside vs. downside risk) and working with providers from different sectors to create risk arrangements. In most cases, plans are looking from within their organizations to staff these groups, reassigning responsibilities if needed, although 6 of the 20 say they are ‘looking for outside experts’ for these roles. The most difficult ‘staff position’ to fill, however, has been ‘pharmacy’ risk contracting staff who can be liaisons between the plan, providers and pharmaceutical manufacturers and work toward finding common ground on three fronts: the best measures on which to base success (i.e. readmissions), how to determine what’s a good outcome (i.e. remission rate), and perhaps the Holy grail issue that may ultimately stall these contracts—how to share in success/savings.
13. Extra Point: Tommy came home with an A, C and F on his most recent round of tests at school. ‘It’s like the good bad and ugly,’ I quipped. He was upset he did so poorly but resisted talking to the teachers to figure out what happened. I told him I was capping his allowance and increasing his chores unless he talked to the teacher. ‘But dad, I don’t get an allowance…remember!!!’ This parenting thing seems a lot harder than healthcare sometimes doesn’t it? If only I had a map or metrics of some kind. Next Friday, we’ll try to find our way around the latest challenge in healthcare business—modern day capitation. I’ll have two guests from the field of capitation and managed care contracting chat about what they have seen lately – the good, the bad and the ugly. Call details: Managed Care Friday Forum – Nov. 16th, 11am, 800-874-4559 (Passcode: COTE37301)