1. New #1: Primary care moves up 9 spots to become the top priority in our 2020 Managed Care Investment Index, results to be released in January. Telehealth, for all its critics, jumps 15 spots to #3 as part of a move to use it as a triple threat: interceptor of care, diverter and treatment. ‘We had been missing the point of tele for a lot of years. It’s a better way to do network steering,’ says Charles Bright, network relations for BCBS. Infusion, a staple in the top 20 recently, moves into the top 5, while PT, which had slipped, moves into the top 10. The changes are generally good for PCPs and subsectors serving them, but mean pressure for others around site of service and payment.
2. Year In Review: Here are the 10 most viewed stories from 2019 in case you missed:
2. Indiana health system taking risk, changing behaviors
3. Avoiding autism’s cliff
4. Caregiver health decline becoming epidemic
5. 560,000 referrals to social services
6. Moms vs Dads
7. Inside the mind of young physicians
8. Brainstorms
9. New mental health ER already at capacity
10. Zero splat points is not the point
3. The Replacements: A new study shows how older patients with joint replacements are recovering at home rather than a rehabilitation center or skilled nursing facility. The JAMA Internal Medicine study looked at 17 million Medicare hospitalizations from 2010-2016 who went home or to a skilled nursing facility after their procedure. The patients who were sent home with home health care services showed the same level of functional improvement, such as ability to walk and go up and down stairs, as those who were sent to a skilled nursing facility. Medicare costs were lower for patients who went home. New York University researchers reported in JAMA that from 2009 to 2012 and 2013-14, discharges to rehabilitation facilities fell from 68% to 34% for patients undergoing hip and knee replacements.
4. Home Alone No More: Utah’s Intermountain Healthcare, a health system that operates 23 hospitals and nearly 170 medical clinics, is bringing an array of services — palliative care, dialysis, primary care and hospital care — into the home through its new Intermountain at Home program. Recovering at home after a hospital procedure is also a focus, and Intermountain has created standardized procedures for hip and knee replacements over the past few years, according to Rajesh Shrestha, the system’s chief operating officer of community-based care. Every joint-replacement patient going home after surgery now gets a thorough assessment to determine the resources that are needed. A care plan is created and a case manager, usually a registered nurse, makes sure that physical therapy, durable medical equipment and home health care are supplied. The case manager also coordinates postoperative care with orthopedic surgeons and makes sure that patients reconnect post-surgery with their primary care physicians. A team of providers is available 24/7.
5. OON Claims: Starting in January, BCBS of Illinois implements a new process for specialty drug claims filled at an out of network specialty pharmacy. If members continue to use an OON specialty pharmacy they may be responsible for the full cost of the medicine. Based on their plan, members may be able to submit a claim to have their OON benefits applied.
6. MA Plan University Partnership: Beginning in 2020, Bright Health will offer Medicare Advantage plans for the first time to Cleveland-Akron, Ohio-area residents through a new partnership with University Hospitals. In an expansion of its existing collaboration with Mercy Health, Bright Health's Medicare Advantage plans will now also be available in the Lima area. Bright Health plans have some of the lowest maximum out-of-pocket limits of Medicare Advantage plans available in these markets. Bright Health's model features a so-called proprietary Care Partner Network developed specifically for Ohio residents based on several criteria, including comprehensive care across specialties, geographic reach, quality of care and operational efficiency.
7. Saliva: George’s fiancée, Susan, has made us all think twice about licking the envelope this time of year, victimized by her own saliva and a toxic adhesive in the classic Seinfeld scene. Saliva tests for drug addiction are much safer than Costanza’s envelopes, but are they accurate? Several insurers say there are a high number of false positive results with these tests, particularly in smokers. These tests are likely to be scrutinized more in the coming years by insurers as they attempt to help in drug detection, but do so affordably. Saliva tests can help with detecting very recent abuse but they only detect abuse for a few days.
8. Extra Point: My 16-year-old played Judd Nelson’s John Bender character from Breakfast Club fame this week, called in for an out of school comment that landed him in the Principal’s office. It’s a twist for a kid whose teachers consider him a leader and for my bride and I who think of Jackie more as Anthony Michael Hall. He slipped up using a phrase in a kind of truth or dare question game with a group of kids who didn’t like it. Said in the huddle during hoop practice and nothing happens. But that’s adolescence: hear social media say one thing, our President say another, your parents push you to be respectful, classy, kind, but bold. Mental health took a bit of a dive for Jack following the Breakfast Club consequences. He was mixed in for a full day with kid repeat offenders - smoking on campus, selling vape, cheating on another test. Our kid’s mistake is a growing pain, character building and while disappointing, doesn’t change what we think of him. Question is, does Santa give him candy or coal?