1. 5: The amount of copay for a Physical or Speech therapy visit starting in 2020 for Cigna HMO members in Arizona, a change from the $20 this year.
2. Concierge Is Back, With A Twist: A company called Accolade will act as the “front door” concierge practice for life science manufacturer EMD Millipore’s 18,000 some employees. BCBS of Massachusetts will administer the benefits but Accolade will be the contact - handling care management, triage, steering members to care, and managing costs. Think of it as a new version of a benefit manager.
3. 2021 National Network: If you’re a physician group or outpatient therapy provider and you’re not in the soon-to-be-coming national Blue exclusive provider networks, or EPOs, you’re probably missing out. Blue plans, according to 37 of the 40 we polled, will start offering these plans in 2021 to members of self-insured and national employers. These so-called ‘high performance networks’ will be based on a soon-to-be revealed quality and cost metrics score.
4. University Free: Showing just how severe the psych shortage is, health plans are starting to pay the full-ride for PCPs to train them on mental healthcare. Where and how it works, and how it may complement the growing trend around telepsych - Click here
5. Downside Risk: Non-solicitation and right of first refusal terminology are new and potentially risky requirements that primary care practices and other healthcare providers will have to manage if entering into contracts with Medicare Advantage insurers. It’s a new world and this piece, based on interviews we did with about 30 MA risk contracting veterans, lays out the trends. Read the story here.
6. Blue & Buckeye Huddle Up: Even though Ohio and Michigan battle next weekend in football, they have partnered to study healthcare utilization. OhioHealth and UM found decreases in ER and specialist appointments, as well as PCP visits, and the Icahn School of Medicine at Mount Sinai echoed this trend, finding a 20% per person drop in PCP visits from 2008 to 2015. Icahn studied a sample of 3.2 billion visits, according to a description of their work in the Annals of Family Medicine. The declines are likely geographic and population dependent. We assume urgent care has taken part of the share particularly in more urban areas, and of course there will be differences by age - less for healthier young adults, less for males 20-35 (based on our polling), and higher for chronics. Authors also suggested longer appointment times for more complex patients and increasing reliance on nurse practitioners and physician assistants as likely factors.
7. Transporting Medicaid Patients: Handoffs have been the core issue limiting progress in preventing overdoses but L.A. Care, a Medi-Cal plan serving LA county, is piloting a 12-month program that provides transportation for its members hospitalized for substance abuse to residential or community-based treatment. This initiative is interesting given that substance use disorder and specialty mental health services are not under the responsibility of Medicaid managed care plans here in California (they are what’s called ‘carved out,’ covered through a mostly county administered system).
8. College Kid Initiative Could Impact Personal Care: A kid at my wife’s school was being evaluated yesterday for potential spectrum issues and during the 25-minute Q&A, the 11-year-old said she is ‘always’ lonely and that ‘no one ever calls her house.’ The problem is addressable because the young girl is in a school setting from 7 to 5 each day, but for seniors the challenge is exacerbated without caregivers. Aetna is launching a new partnership to help combat loneliness among their Medicare Advantage members. Starting in 2020, Papa Inc. will link college-aged caregivers called “Papa Pals” with seniors who need help with companionship, house chores and technology lessons. The program will be available to MA members living in Florida with one or more chronic conditions but likely roll out more widely if effective. This initiative further validates demand for personal care but it also shows that insurers are trying to think about being creative in how they pay for and deliver these services.
9. Pharmacy DownHill: Express Scripts, starting this coming year, will take over home delivery of pharmacy for Cigna.
10. Prior Authorization Stats: Surgery and Imaging were the two most denied services according to several insurers who track prior authorization trends. Denied PA requests for imaging were around 31%, surgery around 47%, according to one insurer who will release the full results to us as part of a 2020 study. Additionally, insurers continue to add CPT codes to prior authorization lists, but remove others. Starting this month, Cigna added prior authorization requirements for 67 of these codes but dropped 40. Regence BCBS added tougher criteria to get hyperbaric oxygen therapy approved for skin grafts while easing criteria for sacroiliac joint infusions. HCPCS drug codes also get attention, like the new requirements for gene therapies like Luxturna. The PA trends are unavoidable and manageable; outpatient providers should track and retain data to help them avoid PAs. There’s precedent with payers like Regence of reducing requirements for consistently high quality providers who try to do the right thing.
11. Extra Point: In less than a week, Janine will ask all 19 and counting at our stained, or as mom would say ‘lived in’, dining table to tell us one thing we’re thankful for, at which time Tommy will spill his water, Jackie will already be onto seconds, my mom will be in the kitchen, and Aunt Edna will be asking where the ravioli is. Yes, in an Italian household, there’s turkey and ravioli. I’m usually the last to go and have little to say other than Salute, but this year I’d like to offer something more impactful. Maybe I can say I’m thankful my kids remember my passwords, or that I’m thankful my gym membership allows us to enter without the key card I keep losing. Or maybe I ought to be thankful Mukue’s acceptance to Springfield College only comes with a $9,500 bill because the next 4 kids won’t be so cheap. Maybe I could say I’m thankful for teenagers, but I’d be lying. I am thankful for my bride and I am no doubt thankful that sometimes I make predictions in the work we do that are at least somewhat more accurate than the New England weather people. I’ll come up with something hopefully but in the meantime, I would say for those who read this point every week and others we’ve come to know over the years, we are thankful to you and hope you all have a restful, happy Thanksgiving. Mangiamo!