560,000: The number of referrals United Healthcare made over the last couple years to social services for its Medicare enrollees. United hopes to start creating diagnosis codes for social determinants of health, like housing, food and transportation…actual diagnosis codes (ICD-10 codes) have been rolled out first for helping address social determinants of health in Medicare patients. Medicaid related codes are next. About 1 million Medicare Advantage enrollees identified a social related issue connected to their health, a United spokesman confirmed. The Parkland Center for Innovation in Texas has done this work too, focusing on finding psycho-social data to identify causes of hospitalization, such as a male who loses his apartment or sneakers for a couple months. How existing physician groups and health systems make use of these codes and services may be an important differentiator, particularly for MA and managed Medicaid positioning. Also watch out for new kinds of vendors entering into capitated arrangements with Medicaid and MA plans to focus exclusively on social services – the precedent is there and this kind of contracting is already beginning to occur in select markets. How much the social service sector takes from traditional healthcare providers is hard to project but it would seem they are at a minimum beginning to take a share of the value dollar.
Snoring Solved?: A poll we did last February of 92 pediatricians revealed that two in five children ages 5 to 15 are overweight significantly and about 75% of those kids suffer breathing issues at night as a result, such as snoring. Regence BCBS has determined in a review that surgeries to fix snoring or obstructive sleep apnea in the pediatric population are investigational; its ‘formal’ policy took effect last June. It did not update its policy for adults.
Consumerism In The ICU: 19% of hospital ‘strategy executives’ we polled earlier this month are hiring ‘consumerism’ officers to help evaluate patient behavior, preferences and other trends, to help it better staff, build and buy. Perhaps they’d benefit from learning more about the differences in decisions and resulting utilization between those single and married. A utilization analyst I’ve worked with, Reena Sanderson, studied healthcare costs for married men and women vs. those divorced, and the total costs and utilization among the divorced population is significantly higher in certain healthcare services. The study was limited to 200 total patients but it was over a three-year period and Sanderson says the married couples who ‘were active together’ had the lowest utilization (based on interviews). Results by geography in a future issue, but meantime the findings make me think of the marriage vows and how they may need an update. See my essay here.
Tiered Network: My oldest son Jack has been firmly cemented as a third tier player on his varsity basketball team, playing left bench because his defense is a little questionable and his agility is below par. He’s 1 of 16 kids in all and he wants the minutes, the competition, but he will have to wait for the players ahead of him to turn the ball over. Well, he got his chance Wednesday night and capitalized by hitting a buzzer beater, but his position on the team remains as shaky as third tier healthcare practices who are struggling amid tightening referral rules, narrow networks and high deductible plans. Like Jack, a lot of healthcare practices are finding themselves--or will find themselves--on tier 2 or 3, needing to wait their turn to pick up volume or get promoted by the insurers. Part of their challenge, like Jack’s, is an inability to get the payer’s attention and show value. For those of you operating these specialty practices the movement to tier-based reimbursement will heat up and demonstrating value creatively will be important. BCBS of North Carolina is the latest to create a tiered network and their work in this area may be a national model to follow. The plan has 2 tiers. Tier 1 providers get better rates based on varying clinical quality and cost measures. Examples: Orthopedic physicians conducting imaging 28 days after a patient’s initial evaluation for low back pain or endocrinology groups (i.e. the proportion of adults prescribed a lipid-lowering therapy who have a diagnosis of hyperlipidemia and CAD but without diabetes). Gastroenterologists, neurologists, cardiologists and OBGYNs are included too. See here for the 2018 scoring methodology.
A New Kind of Center of Excellence: Physician Dan Matthews has offered life-long services, pro-bono, to a youngster and his family he helped last year to figure out the real cause of his behavior. The kid, Aaron, was a 2nd grader and was on an IEP, was diagnosed with an unspecified spectrum disorder and had been taking antipsychotic medications to address outbursts in class and home. Matthews, who heads up NeuroBehavioral Health Systems in Texas, righted the ship – spending about 1 week with Aaron and his mom, doing testing and eventually adjusting the diagnosis and medication. Aaron wasn’t on the spectrum, and the medicine had had been taking that led to 35 pounds of weight gain was completely wrong. His condition was primarily a frontal lobe issue related to Aaron’s development. His new medicine is easier to manage and those 35 pounds he gained are gone. He’s calmer, more engaged, and the stigma that followed him in the halls has been lifted. The diagnosis that Dr. Mathews practice made is an example of the real opportunity the healthcare system has in making better use of regional experts who understand the science of behaviors and can maneuver through confusing conditions like depression, anxiety and autism. While Aaron’s family still can use Dr. Matthews, the beauty of this model is the center is primarily steps away after creating the protocol. But for all these benefits, there are risks, like how to pay for these services to ensure access to them and to ensure the right protocols are established. What’s more, autism and psych practice providers today will likely need to make sure they are linked in with these regional diagnostic centers of excellence. An open question exists in terms of how the health system ought to value these centers. With cancer back in 2008, I recall that Wellpoint at the time was keen on paying for these so-called diagnostic weeks, where the family could go to an MD Anderson or City of Hope to get the right protocol in place. ‘We ought to just pay for the flight and trip to get it right the first time, avoid a lot of re-diagnosing and tumors that move from stage 2 to 3 just because the local oncologists lack the resources, the expertise,’ Dave Tofanelli, former VP of enterprise contracting told me. Tofanelli’s idea was ahead of its time in some respects. These models are now beginning to be discussed more across services, not just behavioral and cancer, but orthopedics and neurology and likely other fields.
Specialty: Hospitals are establishing their own specialty pharmacies to capture more of the savings from prescriptions and have more of the control of patients as they leave hospitals. The predominant feature of these hospitals – they are enrolled in the government’s 340B pharmacy program.
Extra Point: In 2010, my family and I started tracking the outcomes of about 20 adolescent girls who we were teaching at a school in Hartford – their backgrounds as refugees from war-torn Thailand had landed them in our backyard and proved how much was needed at that time to help these kids manage their health, and the health of their families. By 2012, we established a social service model, linking up a single volunteer with each teen and family, focusing on helping empower the girls with exposure to the arts, music, sports and support in managing healthcare. Think getting flu shots or how to talk to a doctor about pain. Or that ‘hospital’ wasn’t just another word for ‘doctor’. These mostly Medicaid eligible families are the very definition of a group needing social support and whose health issues would have almost been pre-determined if not for the volunteer support system. I mention this given United Healthcare’s play in social determinants and what is likely to be a similar move by other managed care companies and health systems, and I suspect that as these models get looked at their will be interest in scaling them, in turning them from local resources to national businesses. This may be a good trend if it happens – because it could increase use of models like this one that help teens who are struggling as defacto heads of household. But those who get involved in these should be careful to understand what makes these models tick, and how to carefully value the services. Wouldn’t surprise me to see a lot of low dollar PMPM arrangements pop up designed to address social determinants but perhaps undermine the value and mission of many of these entities.
