1. Lyft In & Off: The ROI on getting patients to appointments is so good that a network contracting team decided to hire rideshare company Lyft, even though industry commenters say Lyft does not have the same type of credentialing standards for drivers as traditional medical transport businesses (such as medical vans), according to a poll of our network operations managers. Some figured the ROI was good enough just to keep patients from using hospital ERs that they could worry about consequences later, like a lawsuit because the driver isn’t vetted and gets in an accident. Other insurers are more risk averse – one was willing to give Lyft the business for its Medicaid patients to take them to doctor’s visits, but only if they agreed to a more advanced credentialing process featuring 27 points of verification, rather than just DUI and felony records. Some managed care plans and large risk-taking primary care practices think about transportation somewhat differently – they are less convinced about the ROI. ‘I almost see the reverse trend with our population of seniors … we’re trying to bring services to people’s communities and homes, so they don’t need the taxi or Uber, but just need to walk down the hall or down the path–I’m not sure there’s ROI across the board,’ Mark Cavanaugh, MD, said of the new interest by insurers in outsourcing transportation. ‘Depends on your membership.’
2. Oncology Strategies Vary, but Who Owns the Data? Attention to oncology is rising again but the decisions raise some new questions for providers and patients. First, a number of smaller Medicaid MCOs are requesting help from third-party oncology companies to add a layer of medical and drug treatment review and home in on things like off-label prescribing. These plans have seen a rise in incorrect diagnoses and improper treatment plans and ‘related downstream costs like hospitalizations,’ so they will pay a per member per month fee to an oncology vendor to manage the initial decisions. Commercial plans, meanwhile, are taking a different tack, trying value-based models. Regence BlueShield has partnered with Northwest Medical Specialties to implement an oncology initiative, a move that John Partin, Vice President of Network Management, says is an example of the continued move away from payment models ‘reliant on volume of care.’ The initiative is based on Medicare guidelines from the Merit Based Incentive Program. The question for oncology practices is not just how their decisions are being managed, but how their decisions and patient care data are being used, and more importantly who owns the data. Here’s a poll I did back in my days writing for Oncology Business Review that gives a window into the oncologist’s mindset: Click here to read.
3. Farming out Behavioral: In California, in our straw poll of a couple dozen network contracting directors, there’s the sense that Medicaid managed care plans will be responsible for behavioral health by 2021. One plan is doing a retreat this month to discuss its strategy, like whether to use Magellan or do it themselves, or partner with the counties who have behavioral networks now and manage these services. Delegating is somewhat easier ‘because we can just farm it out and audit the delegated entity’ but there’s a cost to that and disjointed decisions in a time when there’s a push to integrate behavioral and primary care. BCBS of North Carolina, for example, takes behavioral in-house across commercial, Medicare, and FEP members in January. For California’s MCOs, ‘broad networks’ are likely initially given the ‘unique nature of patients,’ from SMI, SUD, and general depression to autism.
4. McEnroe the Boat Ashore: Halleluiah, I finally get John McEnroe’s point. In case you missed last week’s Labor Day edition, we debated how the tennis legend’s iconic, if not incredulous baseline arguments serve as a metaphor for healthcare leaders today trying to figure out the right baseline target for total cost of care, particularly as providers start having success in the so-called first set of value-based contracts. Figuring out the initial baseline is one thing but then how does the insurer adjust if the doctors miss it or beat it, or if the baseline moves? How should the contract change? Our poll sheds some light: Click here
5. Repricing: My neighbor used to run a Rhode Island hospital and recently sold his repricing software to Oscar Health, and he’s now helping an insurer build out a hospital network in the northeast but it’s not easy. The market here has been averse to reference pricing, he says. ‘They have lived in a world where the rates are 250-350 percent of Medicare, but those days are eroding.’ With reference pricing, the rates are more reasonable (like 150-180% of Medicare).
6. Extra Point: My 9th grader came home Wednesday saying that several girls asked her to vape in the bathroom, that ‘because you only made the freshman field hockey team…you might as well give up on sports and be cool ….’ The epidemic is quietly finding its way into middle schools too and the healthcare system is having to adjust with new clinical protocols for vaping-related emergencies, and business protocols. For instance, vaping is not typically an option doctors can select when needing to note a patient’s possible substance use. The options for smoking or drinking alcohol are there but with the current vaping epidemic, it’s becoming an issue. Paola Sandroni, PhD, a Mayo Clinic neurologist, says they recently added vaping to their queries. ‘I am afraid vaping should be considered at the same level of risk as illegal substances that oftentimes kill due to the mixing of ingredients, rather than the drug itself,’ Sandroni says. ‘Who knows what is used in the mix?!’ Michigan became the first state to ban flavored e-cigarettes and New York state wants to ban shops from opening. Vaping has been used as a sensation tool effective to quit smoking, yet the marketing towards young kids has been extremely harmful, according to 91% of 372 middle school and high school counselors in our poll last month who say ‘it’s showing up in bathrooms and locker-rooms’ and ‘it’s now an epidemic.’ They are marketed towards kids with flavors and unknown chemicals causing a mysterious disease in the lungs. “Regulated products, bad as they may be, at least must have a known list of ingredients, so you can always trace back to them if there is a bad batch,’ Sandroni notes. ‘But here we are all in the dark.” Our recent vaping story was chronicled here: Click here
A HIP or a Knee? Several of us will be onsite covering the annual AHIP meeting for health insurance plans in DC on Wednesday September 25th. If interested in meeting, send me or my colleague Ashley Chilton a note (bcote@thinkbrg.com or achilton@thinkbrg.com) and we can try to coordinate a time.