67: My high schooler is getting roped into two things – kids asking him to do juul or vape and online gamers called Hofr urging him to predict results from the NBA finals without paying a dime. Jack isn’t biting on the juul offer, thankfully, but he and buddies are all-in on the latest pre-gambling addiction craze Hofr. It seems harmless, but in a straw poll of 74 boys in my son’s high school, 67 of them are betting on these games ‘almost daily.’ This may seem outside of managed care trends but if you look closely it’s another symptom of the iphone generation’s obsession with their apps – and perhaps a clue into how to reach young kids.
Best Buy, Really? The place with all the big TVs has a health strategy, and it’s not too far afield from the biggest trend in healthcare. In 2018, it bought an emergency call service called GreatCall to add to its home-based motion sensor and monitoring technology to help aging seniors. You could see risk-taking super groups promoting such a service and technology, perhaps MA plans too. Perhaps offering discounts on flatscreens or DVDs if they even exist in 5 years. Can’t you just see it – while Best Buy installs the sensor in your mom’s condo, you ask the technician if he has GeekSquad credentials to help reboot your laptop.
Golfers For Cataract: Not all of us have Danny Noooan to carry our bag down the fairway and track our wayward slices. The #1 question that ophthalmologists get from male patients who are about to get cataract surgery is, not surprisingly, ‘how soon after can I play golf….’ What is often not discussed, is just how important the surgery is for these golf-obsessed seniors who don’t hit it quite as straight and can’t see the ball off the tee like they used to. A Medicare Advantage plan’s utilization analyst, Mary Kellogg, says the plan is looking to study cataract utilization trends and related social factors, like surgery by gender, climate and even something as obscure as whether the patient is an avid golfer. ‘Do they need it to see the ball better, or do they need it to drive to the course…two different things’. While it seems unlikely that denials for cataracts increase drastically, with the increase in MA and medical management of vision, it wouldn’t be surprising to see greater analytics around medical necessity. A more likely debate and trend to at least acknowledge is the likely market move to more in-office cataract. 31% in the poll said they are thinking about it, if the reimbursement is there. Questions about infection and anesthesia safety factors exist but there are outcomes – a Kaiser spokesperson told us they have performed about 50,000 in-office cataract procedures without any eye inflammation complications.
Gonorrhea Precursor: Kramer made it look easy to diagnose Gonorrhea back on Seinfeld when he compared his ‘burning pain’ to the haunting memories of lost love. The theatrical performance for medical students in training was ahead of its time, correctly, if not comically depicting how it’s important to get to understand what’s going on with patients to best direct treatment. My dad says his ‘antenna is now up’ when he is struggling to get a teenage girl to improve range of motion from shoulder pain and spots potential depression or anxiousness. He asks about life at school and home while helping his patient’s in clinic, not as idle chatter but as a way to see if anything may be preventing improvement or causing the pain. He knows this since a past patient eventually divulged an eating disorder after 3 months of visits. I mention because as United and other insurers begin to pay for providers to identify, document and then address social determinants, there will come a time where the payer world will want to see results (lower cost for things like procedures, drugs and hospitalizations) for this investment, as well as earlier identification of the correct diagnosis. When evaluating your practices, think about how well your providers are trained in diagnostics – not just relying on a lab test or scan, but in the art of conversation.
Burrito Bowl Worker Accident: Chipotle is for my kids what KFC’s crispy chicken buckets were to a generation of kids who waited for dad to come home with dinner on payday in the 80s….well, for Chipotle and other big companies like Conagra, Geico, J&J, JP Morgan, Labcorp and Target, they use a third party called Broadspire to handle worker’s comp–all the claims and cost-saving services associated with these cases–and starting this month if your healthcare group or doctors provide treatment to a worker’s comp patient who works at one of these businesses, your reimbursement will be based on Anthem’s fee schedule. This change likely flows through to these employers in many Anthem states, not just Indiana which announced the change.
Fertility Pharmacy: Starting in July, two pharmacies – BriovaRx and Walgreens’s AllianceRx – are out of the Blue Massachusetts network for ‘fertility medications’ so doctors and referring providers are being advised to send patients to Freedom Fertility Pharmacy, Metro Drugs, Acaria or Village Fertility.
Site of Service Intervention: In a new but not surprising move, UnitedHealthcare’s Community/Medicaid plan starts to conduct so-called site of care reviews for PT, OT and Speech therapy starting in June. First, they’ll give a go-no go decision and, if authorized, will review the ‘outpatient hospital site of service’. This trend follows the emerging use of site of service for radiology/imaging and infusion.
Radiation Policy Change: Evicore, which handles medical policy development and pre-authorization for insurers, including its parent Cigna, has made some big changes to guidelines for radiation therapy for soft tissue sarcomas, treatment with Lutathera and proton beam therapy. MA and fully insured impacted.
Post-Traumatic Stress: PTSD benefits for first responders in Connecticut are likely under a new proposal. As a hard-to-treat condition, it seems to be one of the underappreciated and often missed side effects of pain, injury, and surgery, and of course grief, loss and trauma. Says Rachel Touncey, MD, an internist by training who’s now working with ‘physician groups trying to move into risk taking’: ‘I don’t see protocols trying to get at this. Completely avoided…and yet it’s often the thing that hinders recovery, or explains behavior change’
All Bets Off Kenny Rogers: More payers are covering therapy for gamblers but not in every setting and not as restrictive as you might think. Excellus BCBS allows OP therapy for gamblers without pre-approval. Residential, partial hospitalization and Inpatient services are thought to be investigational. The biological dad for our oldest foster kid has struggled for a number of years with this behavior–using salary to fuel the addiction, putting his family and our oldest in a tough place at times–but what is clear is that social factors have as much to do with the cause of this behavior as anything. How OP therapy addresses these factors will be important for this benefit and treatment to have any success.
Extra Point: At about the same time as my oldest son was leading the marching band down main street on Monday my dad was pulling a Richard Kimble back home, wrapping a deep shin wound with one hand using amateur tape and gauze like the Fugitive character, driving himself to the urgent care in what was a race against time. He had fallen in the garden trying to relocate a hosta only to slip or get dizzy and slam his right shin into a rock. He would later tell me he ‘wanted to get it stitched up before mom found out….’ But the so-called 24-7 urgent care was closed—two of them in fact—so I made my way to dad’s house to pick him up. We averted going to the hospital ER, finding the only urgent care open in the region. The PA was sharp, and a great teacher – allowing a Bay Path College student just enough independence to clean the wound and put in 8 stiches on his own, with a small bit of oversight. I think back to Memorial Day – yeah, I missed the barbeque, but I spent a day with a veteran, my dad, and stories about his penchant for falling and first aide. Here’s to all the vets out there.
