1. 4: The number of vitamin D tests you can do per year, starting in January, if treating United California Medicaid patients with certain conditions, as a result of what the plan calls ‘recent clinical evidence about the test’. We would not be surprised to see this policy find its way into United coverage policies beyond California.
2. Homeless Healthcare: One woman’s story chronicles the positive impact of a program in Massachusetts designed to address gaps in care for this population: click here
3. Sound Off--Sorry Moms: United’s Community plan for Medicaid patients will no longer consider ultrasounds medically necessary if only done to determine the fetal sex or provide parents with that cool photo for the fridge. Detailed ultrasound fetal anatomic exams are also medically unnecessary for a routine screening of a normal pregnancy.
4. Family Ties Recent Index Results: Jen’s dad had to be admitted to a psych ward a couple weeks ago. The dad suffers from Parkinson’s. That day and those preceding required the family to be all in for dad. Missing work, being absent from their own life and families, stressed and helpless and eventually sick themselves. This is a real issue across the US as American’s get older and their conditions more complicated the families around them suffer, playing nurse, therapist, care coordinator and eventually….patient. The managed care investment index of priorities is out and there is a new number 1 and seven new entrants (index here) and a bit of a softer, gentler theme around services designed to help families. There are signs anyway: better coverage emerging for things like family counseling in the home to respite benefits and pay to caregivers for providing personal care to family with Alzheimer’s or Parkinson’s. Addiction treatment has moved into the #1 spot this month, edging stalwarts like Orthopedics and Cancer Treatment. Autism, not even in the top 100 five years ago, cracked the Top 10, outpatient psych moved into 11th and telemedicine, even though it dropped 5 spots, remained on the list. What these services have in common–they are all hard to manage but designed to support family through crisis. And the broader theme if you listen to the payers lately is that there is an underlying wave of support growing for them, or at least to try to figure out a better way to manage and pay for them. As early as 2019, you’ll see more payers looking to move these services from fee for service into value based payment. We will see how quickly this evolves, particularly as it’s taken many years just to get attention. Click here for index
5. BluePrint: ‘We recognized that the providers were struggling and we needed to listen’ – Kelly Lange, who directs health reform for Vermont’s Blue plan, talked to us this week about an innovative effort underway to allow providers to take risk for managing addiction and mental health and other conditions. Magellan, the plan’s former benefit manager for behavioral health, was costing the plan many times more than what the plan is now able to spend to manage patients inhouse. Other plans, like Care1st, have moved behavioral inhouse. Providers, who complained about the hurdles to getting approvals, are now able to manage and treat without interference, but get support from the payer’s case management team.
6. Compounding: Individual Empire BCBS Medicare plans will move compound drugs off formulary beginning January 1, 2019 with the exception of home infusion drugs. Group-sponsored Medicare Advantage members will continue to have compounded drug coverage although these drugs will require prior authorization. Compounded home infusion drugs will continue to be covered for both Individual Medicare and group-sponsored members without prior authorization. Members and/or providers can request a non-formulary exception for compounded drugs.
7. Capitation Debate: In case you missed it, check out our 30-minute podcast on managed care developments and capitation: Friday Forum
8. Extra Point: Coach told us today that our 8th grader, Sophie, will see significantly reduced minutes during Sunday hoop games because she won’t be playing in Saturday games to attend dance classes. All in or sit pine basically. We said ‘sounds good.’ There’s a point when we recognized what our kid likes and doesn’t like, and what matters – she loves the arts and loves performing and if dancing 2 hours a week fills her up, it’s worth missing a basketball game. Going to practice and learning, being part of a team – all important. Playing a sport 5 days a week and giving up other things at age 13 – not a great idea; I hear more and more counselors tell me that the root of adolescent crisis is often pushing kids too much. We called the coach's bluff in a way here as he was hopeful to keep Sophie in the mix as a starter for games because she can guard people and dribble. But there are 13 kids on the team and life is too short – and Sophie says maybe missing Saturday is a blessing for her teammates who’ve been sitting pine and need a win if you know what I mean. We just saw statistics from Ditch the Label, a youth organization, about the percent of kids suffering from things like depression. Many of them bullied for how they look, or what team or club they’re on. Many conflicted by decisions made for them around sports. 50% suffer depression. A lower but meaningful number suffer eating disorders, and even try to take their own lives. The stats come to life starting at age 13. Doing what we can to encourage balance, reasonableness, and a bit of humility in our kids is our effort at helping them manage through adolescence. It’s a daily struggle…but here’s to the journey.