1. 307: That’s the amount of mass shootings in the U.S in 2018 up until November but there are signs that the market is trying to reverse the trend. Walt Disney Company is expanding a national program focused on helping kids who suffer from social isolation in elementary school. Parents of some of the children killed in the Sandy Hook shooting are involved. The program will be available to schools at no cost and aims to train 2.8 million students in 6,000 schools by 2022.
2. Cardiology The Next Target: Several cardiology procedures will now require pre-approval and post-service medical necessity reviews under a new utilization management program that BCBS of Florida, BCBS of Louisiana and several other plans are starting. Procedures performed in an office or outpatient setting will be impacted, including non-emergency procedures like total knee arthroplasty, knee manipulation under anesthesia, knee ligament repair, hip arthroplasty, echocardiography, diagnostic coronary angiography and aterial ultrasound. The UM company AIM will run the program. Both commercial and Medicare plan patients are impacted.
3. ENT Treatment Investigational Status: Take note if you are exploring the ENT market. Several Blue plans have determined this month that drug eluting sinus stents and implants for post-op use following an endoscopic sinus surgery are investigational, in other words these stents and implants aren’t covered. The policy also will apply to patients with recurrent sinonasal polyposis.
4. Autism Oversight Change: Several Blue plans have adopted new coding guidelines for ABA services. In Louisiana, there’s a new rule that impacts the ABA supervisors (the BCBAs). When these BCBAs are doing a protocol modification visit with a child, they cannot also bill for the tech visit at the same time (billing the protocol medication 0364T code with 0368T is not allowed).
5. Essential Health: Health Care policies sold in Connecticut must cover treatment including emergency room trips, outpatient care, mental health services, prenatal care and ongoing care for a baby throughout childhood regardless of what happens to the Affordable Care Act, according to a new CT state law on essential health benefits.
6. MidLevel Cut: Beginning January 1, 2019, Anthem Medicaid in Kentucky will reduce the reimbursement rate for all midlevel practitioners, including but not limited to advanced practice registered nurses, physician assistants and nurse midwives, from 85% to 75% of the Department for Medicaid Services physician fee schedule.
7. TeleHealth Expands: BCBS of North Carolina has just added a new telehealth benefit for ACA plan members. MDLife is the vendor that will administer the program, with visits ‘equivalent’ to a primary care office visit. In our poll of 287 health plan network, medical and strategy officers last week, 59% said emerging areas of need and interest for them are finding ways to more effectively deliver telehealth and tele-psych services this year. One plan said they are ‘reviewing more than 3 dozen vendor proposals’ targeting a range of populations – employers, kids, seniors, rural, and Medicaid. Commercial plans are increasingly using telehealth to intercept urgent care patients, saving ‘$120-$175 on a typical urgent care case…..’many of these patient issues will just self-resolve, so the idea of the hotlines or telehealth encounters is to intervene earlier and advise the patient….but if it’s a psych issue, we can refer to a counselor,’ Marty Frestreiter, RN, a BCBS hotline department manager said. ‘Problem for us is amassing enough psychologists to handle that volume and making sure people are aware to use the hotline.’
8. College Health: Back when I went to college if you were home-sick you called mom or dad collect from a rotary dial phone in the dorm hall common area. It was never a good feeling when they wouldn’t accept the call. Today, home-sickness has taken on new meaning with more attention in colleges to the risks of depression and isolation. Colleges are likely going to invest more in telepsych services to try to alleviate pressures on their campus clinics. Many report getting inundated with psych visits they can’t handle – ‘we had 36 kids come in this week alone, about one-third we had to drive to the hospital because we were concerned about their emotional well-being,’ Rick Stippert, a health clinic manager said about students at his university in Illinois. ‘We aren’t equipped to handle the volume of students who are 19 and away from home and really struggling emotionally…’ notes Tracy Chamborg, a director for an Indiana University clinic. She says there is a need for a tele-health solution.
9. Extra Point: Tommy and I did a little math last night, counting up the number of games he and his 3 siblings and me and my wife had played since school started in September. Out of 106 contests, we had won 20 as a family collectively, lost 83 and tied 3 – and this has been a good stretch if you ask me. Losing is contagious and depressing but at times pretty funny to watch and almost always educational, at least in our household. I feel like my wife and I spend more time managing our kids emotional well-being on the heels of losing, as we do about just about anything else. Losing games, homework, friendships, parts in plays – it’s an endless conversation. Physicians and therapists face a similar challenge these days as they seem to more easily lose patients or reimbursement, and yet seem to have more pressure to prove they can help patients manage the ebbs and flows of disease, the loss of function, sight, hearing and mobility. I asked a group of pediatricians at a meeting last fall what was the number 1 thing they felt they were losing and at least 9 out of 10 said ‘patients to urgent care’. It was an interesting comment because about the same number also said they felt like that this had forced them to re-think their practice and re-focus more on the patients they did have and how to help them. Three of them decided to add a service to help diagnose autism, others created a nutrition and exercise wellness center, and one created a ‘class for parents’ to educate them on raising kids. I think this new era of primary care will likely create more of this kind of innovation. I know personally, it’s not that easy managing the downsides of my own health, much less my aging parents and adolescent children when I’m so spread thin. Here’s my own list of the things I seem to be losing the most these days…hopeful that writing it down will motivate some change and, with any luck, some winning: click here