1. 16,752. No, this isn’t another Rent song, it’s the average cost believe it or not that a diabetic person will spend on average each year on medical costs, according to a recent study by the ADA. Cigna and Express Scripts introduced a patient assurance program to cap the out of pocket costs at $25 for every 30-day insulin prescription. Cigna says this reduces the out-of-pocket costs for insulin by 40% or more and improves affordability of insulin costs for people with diabetes. The Patient Assurance Program will be available to members in participating non-government funded pharmacy plans managed by Express Scripts, including Cigna and many other health plans, with out-of-pocket costs for insulin greater than $25. Out of pocket costs for insulin include deductibles, copays or coinsurance.
2. Allergy UnBoost: Reimbursement for Allergan immunotherapy is going down, according to a policy effective this month from BCBS of Tennessee. The commercial payer used to define a dose of allergen immunology as 1cc of extract and limited reimbursement to 30 doses per day but it will now use an annual limit, allowing up to 160 doses per patient per year.
3. Evaluation Management Switch: Beginning in May, Anthem may deny your evaluation and management services if billed with a modifier 25 on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record. The reason is Anthem’s audit identified that providers often bill a duplicate E&M service on the same day as a procedure even when the same provider (or a provider with the same specialty within the same group) recently billed a service or procedure that included an E/M for the same or similar diagnosis. The use of modifier 25 to support separate payment of this duplicate service is not consistent with Anthem billing rules, a spokesman told us.
4. Autism Meet The GI: So many of you are following the growing autism treatment field or GI sector – well marry the two and you may solve a complex condition common in kids on the spectrum. Many children with autism have gastrointestinal issues. ‘The human gut and brain interact in complex ways, and abnormal conditions in the gut may predispose individuals to neurodevelopmental disorders,’ Arizona State University have found. 95% of children with autism have co-occurring conditions, almost 5 on average.
5. Genetic Hoop: UnitedHealthcare now requires genetic and molecular testing performed in an outpatient setting go through a pre-approval process if ordered for members in Rhode Island and New Jersey. Pennsylvania Medicaid members would need the ordering physician to get approval starting in July
6. Breaking Down Walls: Children’s Hospital & Medical Center in Omaha says it wants to expand access to its pediatric psychiatrists across the rural communities of Nebraska and Iowa and so it is designing a telehealth program allowing the specialists to treat new and existing psych patients remotely for all conditions typically seen in outpatient clinics: depression, anxiety, ADHD and autism. The marriage of clinic, hospital and psych services is emerging as a top focus in the health system – if you’re an owner of a private practice, think of these developments as either opportunity or threat, but at a minimum a sign that hospitals are coming downhill and breaking down the walls of the hospital campus.
7. Observation: In interviews with a lot of different medical directors I’ve come to appreciate that risk taking medical groups seem to take observation for granted – that many, in their quest to manage cost particularly for Medicare Advantage chronically ill patients, tend to ‘underutilize’ observation. IP days reduction and readmission reduction are established goals, but with patients who have a lot of chronic conditions, observation is a reasonable level of care. As you evaluate your own group’s risk taking capabilities or potential gaps, look at how often (or little) observation is used. There are rules to follow, too. BCBS of Michigan’s medical team noted that they use Interqual criteria to determine (a) whether the patient should have been in observation to begin with and (b) whether they’ve failed in this setting. Blue Michigan requires 48 hours of observation to complete workup, treat and/or stabilize the patient for discharge. An admission may be approved if the patient fails treatment for say, dehydration.
8. Out With The Insurer: CHRISTUS Health announced that hospitals in Texas and Louisiana will no longer be accepting Cigna health insurance due to the hospital group and the insurance company disagreeing on a financial compensation. The hospitals and clinic went out of network in March. CHRISTUS Health is a not-for-profit health system that includes Good Shepherd Health System, CHRISTUS Mother Frances Hospitals - Tyler, South Tyler, Jacksonville and Winnsboro and CHRISTUS Trinity Clinic.
9. Alexa: I’m not going to lie – Alexa creeps me out but, say this, she’s making her mark in healthcare. Amazon announced new software this week that allows health care companies to use Alexa voice tools to securely transmit private patient information such as progress updates after surgery, prescription delivery notifications as well as trafficking patient information that is protected by the US's health privacy law (HIPAA). Large health businesses such as Cigna to Boston Children’s Hospital were among those who helped to build the six different voice programs. Alexa now has access to more sensitive details of patient’s medical conditions. Express Scripts, the pharmacy benefit manager acquired by Cigna, built a tool to allow people to check the status of home delivery prescriptions. Boston Children’s Hospital built a program enabling parents and caregivers to provide clinicians with updates on their progress after surgery and get information on post-operative appointments. Alexa will now be able to book patients their urgent care appointments.
10. Rehab Tweaked: Empire BCBS of New York has a new rehab program effective this July that will transition medical necessity review of rehab (restoring function) and habilitative (enhancing function) services for fully insured members to AIM Specialty Health (AIM). This means a AIM will make the call on whether PT, OT and Speech are necessary. Remember that AIM is highly focused on controlling UM for pain and imaging and gaining increasing share in the benefit management space with Blue plans, as well as Anthem (which owns them). How AIM uses data to influence future coverage, reimbursement and benefit design policies will be important to watch particularly for those in this space.
11.Social Experiment: The National Quality Forum (NQF) and Aetna Foundation have launched a 9-month project to find ways to promote payment methods that reduce health disparities and by addressing how things like housing, transportation, and nutrition can be barriers to better health. The duo will ‘look for pioneers across the country’ - payers or health systems, or even entire communities. The idea is to find those ideas that are repeatable and scalable. My own group that my wife and friends and I started 10 years ago is a small social service for refugee families in Hartford focused on helping teen girls from Thailand - it uses a volunteer-led model to reduce the impact of social and economic challenges on about 100+ kids. Scaling something like this depends largely on volunteers. Parallel to this NQF-Aetna effort, United and the AMA are creating two dozen new social determinant codes using a combination of medical data and self-reported social data. Details here: https://thebehavioralhealthhour.com/2019/03/29/560000-referrals-to-social-services/
12. Anesthesia Up: The conversion factor used to calculate anesthesia base units for anesthesia procedures will increase by 1.5 percent under a new BCBS of Michigan policy taking effect in July.
13. Extra Point: Patagonia is not a real place I told a colleague this week. At best it sounds more like the name of the village in The Princess Bride. Which reminds me…the book is making a comeback in my house as is the film, particularly that scene when a fragile Wesley challenges Prince Humperdinck in a battle ‘to the pain’. It would seem the healthcare sector is trying to align with this mantra, if not going further. Policies to force physicians, PAs and NPs to encourage conservative treatment before pills and injections and devices are gaining momentum. Even Inland Pain Medicine, a large group practice in California, promotes Yoga as a means to avoid pain and reduce its triggers, like depression and anxiety. Chronic pain is often the result of undiagnosed PTSD – which I’ve learned is very common in teen girls who grew up in refugee camps….and Inland’s medical team notes that those pushing for higher cost procedures like spinal cord stimulation or injections without fully evaluating a patient’s history and mental health are not doing the right thing. Spinal cord stimulation needs to be carefully evaluated (as it will be by insurers), the group says. Pain appears to be moving away from something to merely manage, and toward something to avoid.