1. 16: Number of cancer groups participating in Humana’s new oncology payment model for Medicare Advantage and commercial patients. The program is in its 5th month – but efforts to pay differently for cancer aren’t new by any stretch. Before the days of ‘value-based payment’ there were pioneers at Aetna and Humana designing shared savings models from scratch. The model is the fourth for the plan to target specialty services – orthopedics, maternity, and spinal fusion for MA patients.
2. The Cayman’s: Perhaps not a fit for the big insurers, but a handful of medical groups taking global risk told us they have started to use a business called Price MDS that helps groups avoid super high cost drug expenditures or treatment costs, like 80% below typical levels. In a common example, there are some rheumatology drugs that are in the millions each year so ‘this network helps us send the patient basically to a 1-day vacation to an outpatient center that’s fully licensed and meets all the requirements, for ‘mere pennies’ – it’s a good model for risk takers, and an indicator for any risk taking practice – where are you sending patients and are you sure you know the cost of that decision?
3. Consult Code Out: Starting in October, United Healthcare stops paying for so-called consultation services billed using codes 99241-99245 and 99251-99255. The appropriate evaluation and management codes must be used instead.
4. Cap Up Front: If you’re trying to contract for risk, make sure to get a payment up front to cover your PCPs services in advance rather than having to float until reconciliation of the payments takes place. The up-front cap can be something like $75 or 110% of Medicare – there’s a lag in the calculation, so this is one way to at least cover this until the claims for ER and IP are tallied.
5. Latest Social Measure: One unhealthy day equates to 10 hospital admits per 1,000 people or $15.64 per member per month in additional costs. This is the latest statistic that insurers are starting to lean on to shape programs to address social determinants of health. In what they’re calling Bold Gold, Humana says 5 of 7 communities reduced unhealthy days last year. Loneliness, for example, causes Medicare seniors to have an average of 24.4 unhealthy days a month; food insecurity averages 26.6. But there are community programs that are beginning to address these stats – and for provider groups like medical groups taking risk, these are indicators of a rapidly shifting trend in where the MA value dollar is headed. In New Orleans, those with CHF had a 9% improvement in unhealthy days due largely to a food bank program and San Antonio reports a nearly 10% decrease in unhealthy days. In contrast, some cities where Humana has members have struggled – including Broward County Florida where unhealthy days increased by 4% as did depression prevalence among members. By the end of the year, the insurer hopes to ‘screen’ 1 million for social related determinants of health.
6. Ankle Over Budget: An orthopedic group in Arkansas says it had been doing well in a bundled pay program but it is struggling lately ‘because a lot of our patients have chronic conditions and so rehabbing them is a lot harder….and we’ve had some situations where the patient didn’t comply and had complications….,’ Michael Slavan, the executive director for a Ortho Associates says. The group says that they have gone ‘over budget’ most commonly with foot and ankle procedure patients and with teenagers who play sports and are coming off of a diagnosis related to a baseball injury (like multiple directional instability, or MDI). Slavan agrees that one of the biggest gaps his group has faced is inability to have consistent PT as well as address the mental health/psych issues of patients in rehab…’If you’re doing bundles, and you don’t have the full suite of services, I’m not sure how you have success.’
7. Mawidge: As the Priest said in The Princess Bride, this is what brings us together, today….and if you’re in the healthcare field in one of these specialties, you may want to think about marrying or at least dating these insurers who we might argue will be the most important to your growth given their recent efforts to focus on specific diseases. For pain and PT, it may be Cigna and its Express Scripts and Evicore arm looking to create centers of excellence. For behavioral, it may soon be Anthem or Beacon (or perhaps a combined entity) given both companies recent investments in the psych arena. For social determinants, UnitedHealthcare. For home health and hospice, Humana – although be careful about the company’s Kindred and Curo ownership in some markets. For addiction, it may just be Shatterproof, the non-profit. And for surgical specialists like orthopedics, GI and ENT, and diagnostic services like lab and imaging, it may not be traditional large group insurers but more so large risk-taking medical groups who will need reliable specialists set up to do the right thing at the right cost.
8. College Course: When I struggled in college, I played late-night floor hockey and then hit the local Denny’s for a short stack of flapjacks….that was how we handled the anxiety of finals or the ups and downs of being away from home. But things are different now in the age of social media. Boston University has one of the nation’s only programs for students needing mental health support after having to leave the school due to depression or anxiety. In response to the needs to help college students, Beacon Health Option now has virtual counseling. For ‘primary care and psych providers’ the new program is important because it is the latest sign that the managed care is taking health inhouse, creating its own stable of practitioners
9. PTSD: 53% of parents who have senior moms and dads say at least one of their parents has had a post traumatic stress condition due to a childhood incident, time serving in the war, or most commonly due to the loss of a spouse. Of the 429 polled, about 220 said the PTSD ultimately led to alcohol abuse, dehydration or malnutrition, and eventually to a hospitalization due typically to a fall in the home. PTSD is likely top of mind for many veteran’s families during this Memorial Day weekend. Question is whether your businesses are equipped to train practitioners to identify this condition early enough in care.
10. Extra Point: Coach told us this past winter that our 8th grader, Sophie, will see significantly reduced minutes during Sunday hoop games because she wouldn’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. We called the coaches 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 – Sophie said 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 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. For background on our study first published last week on the impact of sports on families and health, click here: https://thebehavioralhealthhour.com/2019/05/17/losing-beats-winning-2/