1. 700: Number of direct primary care practices in the US via a new coalition of doctors who provide a kind of low-cost monthly membership to serve people without insurance and those with high deductible plans. The new delivery model has a concierge feel with higher touch care and a new-age pricing model: Memberships are $75 a month for adults, $25 for those under 21, with unlimited telemedicine and office visits and house calls for $25. Labs and meds are charged at wholesale cost plus 10%, according to Jonathan Bushman, who runs Reliant, a practice in Oklahoma that’s part of the emerging delivery model. There’s sort of a split view of these models among insurers – on the one hand several have told me they think these groups ‘mostly cater to the worried well’ while others have said ‘we could learn a lot from these models’ in terms of how to manage care.’
2. One if by Land, Two if by IVF: Fertility benefits seem to be improving a bit and as they do it’s no surprise to see managed care tighten the reigns a bit on payment policy even as they expand coverage. Aetna, for its part, is trying to help employers find balance by offering a benefit but a cost effective one. Starting this year the plan will cover the entire cost of the first I.V.F cycle if one embryo is transferred instead of two or more, and if that attempt fails, the insurer will cover the cost of a second attempt using a single frozen embryo. (If the woman’s plan limits the number of cycles covered, the second attempt will not count against that limit.)
3. Shatter This: More important than a single payer, Shatterproof, starting this year, enters pilots with New York, Massachusetts and Louisiana to deploy its principles of quality care for addiction treatment as a guide for insurers, physicians, hospitals and ultimately families facing addiction, according to Jasmine Bass, a spokesman for the non-profit, who I chatted with at the National Council for Behavioral Health on Monday. Shatterproof has ~19 insurers signed on, including the BCBS Association, with a goal of eventually using state scoring of treatment programs to advise consumers via a national online portal on where to go for treatment in their area – think ‘the Mayo of addiction treatment,’ but based on a national set of data. Winners are those who make their way onto the list, several insurers confirmed to us at the meeting. A rollout to other states is likely, Bass said. To see parent views on this topic from a poll we did a couple years ago, click here/ and scroll down to ‘Addiction – What Do We Do?.’
4. Mommy Dearest: Parents-to-be will have a new metric to compare hospital labor and delivery sites as the Joint Commission will publicly report C-section rates starting in 2020. The data ‘will absolutely factor into my decision’ says Kelly Flores, who is set to be married this summer and ‘says she and her beau likely start ‘trying later this year…since I’m in my 30s.’ My dad would say wait a few years but given Kelly’s age it’s logical to start and with public data she and 79% in our poll of woman 25 to 35 say the ‘rates would definitely be a factor’ particularly if ‘my OBGYN were associated with the hospital that has the high rates. Until now, the Joint Commission has the data, but hasn’t made it public. C-Section rates above 30% in a single year or over a 2-year period will appear to future parents as having higher rates (denoted with a minus sign, which in consumer speak ‘sort of seems like an F’ said a mom we polled. More broadly, this trend is important when you think of the movement to better attract moms to woman’s health groups who are able to provide a great experience, spend time with woman, and head off complications before they arise. Hospitals have earmarked behavioral health and woman’s health as two ‘rising’ stars in their service-line efforts, and it’s no surprise that the two sectors are being touted as ‘likely partners’ in a marriage of services that could be attractive in addressing the cost of care for woman in their 30s to 50s – ‘a key audience from my perspective,’ said a network development director for Anthem, ‘because you’re talking about both the consumer of care and the influencer of it for teens, husbands, and seniors. If we can set up a network and benefit design that works for this population of woman, we may have found something…’
5. OffRoad to Value: ‘Someone said payment is a marathon and not a sprint….only difference is with a marathon you know where you’re going…we haven’t quite figured it out yet…’ This from Sander Koyfman, MD, behavioral medical director for Wellcare in New York who obviously hasn’t seen me wander off course on my bicycle marathons. Dr. Koyfman, a psychiatrist by training, said this with an earnest smile and a bit of a plea for providers to be patient with the government-sponsored health plan. He says they have great idea for a pilot but ‘it takes 3-4 years’ to get it going or to the next level. ‘You have to pick the right metric but that’s not easy…particularly with behavioral health.’ The key to value design in many respects is the willingness of the payer to share data with providers. Anthem’s Jeff Walter, a director of payment innovation, says they gave a large group in Texas their admission, discharge and transition data and ‘the group used it to create a crisis response team and target superutilizers.’ But there are barriers to consider too: ‘Candidly we have concerns about data integrity,’ says a Magellan Complete Care spokeswoman … ‘we have more than we can make sense of but want to make sure we’re giving you data that sets you up to be successful, that we’re not giving you the wrong data.’ The plan’s corporate compliance legal team is cautious, so Magellan is ‘in a catch-22’.
6. Clinical Measure Demand: In an audit of length of stay decisions for a subset of its members treated for eating disorders, one regional plan found that more than one third of discharges for anorexia patients occurred before the patient had reached 75% of their pre-condition weight and in a review of patients who were allowed back to the same program after relapse for bulimia, nearly one-half were found to have been abusing alcohol even though at discharge they were no longer vomiting. Commercial plans are acknowledging through these audits that they are paying a lot for care without any real post-rehab recovery or a sense of how to manage these patients or determine what’s a good outcome.
7. Rent Knockoff? This one sounds more like a Rent song than reality….but United Healthcare says it has made 560,000 referrals in the last couple years to social services for its Medicare enrollees. And it 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.
8. ExtraPoint: My youngest, Tommy, was in the principal’s office Tuesday because he, get this, spread a rumor about two kids...it’s no surprise if you ask me. See Tommy is a sixth grader in limbo – a foot shorter than the shortest kid, anxious about doing anything new, fixated by Dude Perfect and FortNite, and finding his way with 3 older, confident siblings. He punished himself by angrily burying his head in his pillow for 3 hours. Wednesday, after a long day at school, he and I hit those low-compression tennis balls out on the street. He broke a good sweat and hasn’t touch the iPad in 3 days. He’s healthier. The power of movement is gaining momentum but remains underappreciated in my opinion. It ought to be a greater part of treatment plans and school curriculums , and it appears that some medical groups and health systems agree. Barry Ostrowsky, CEO of New Jersey-based Barnabas Health, has said that insurers don’t really reimburse for wellness initiatives but this mindset is starting to change as health systems take greater risk and insurers like BCBS of Rhode Island give grants for school-age play programs. Barnabas, like several systems, now operate fitness centers, and a medical group in Minnesota – a state with a lot of Medicare Advantage patients – is contemplating opening one in its building. United is going all in on housing investment featuring wellness centers for its Medicaid population and it wouldn’t surprise me if more medical groups that move into risk arrangements start to affiliate or operate their own ‘on-site track and fitness centers…’ But what would really be compelling is medical groups starting tournaments that match patients, ala the Biggest Loser, with a practice’s new ‘Physical Fitness Director’ ‘seeding’ patient groups ala the NCAA tourney. Teams of 5 would compete in relay races or hoops or swimming, featuring a cross section of patients like a diabetic with a 6.9% hemoglobin A1c level paired with patients with varying degrees of depression or cardiovascular disease. Make it to the Final Four, no cost share for a year. This all may seem more fantasy than reality, but then again who would have thought we’d be paying for things like housing, telepsych and applied behavioral analysis?