50,000: The number of Medicaid enrollees Molina gains in Illinois’ Cook County now that it has just agreed to acquire the Medicaid managed care organization NextLevel Health Partners, which is a community-based health plan focused on social determinants.
Home Rx: Beginning January 1, 2020, members of Oscar’s insurance plan in New York can select Capsule’s same-day pharmacy service through the Oscar app to start receiving meds straight to their homes at no cost.
Yelp The Doctor: Cigna is now giving 5 specialists access to patient reviews and will likely add 7 others this year to help both providers and patients figure out who’s nice and who’s effective. If you think the insurer won’t use this in benefit, contracting and reimbursement decisions, think again. Doctors get an initial look at the results and can challenge them but, much like those too-close-to-call NFL catches, few are likely to be reversed. By April, patients should be able to access comments and recommendations through the provider directory. Podiatrists, ophthalmologists, dermatologists, telehealth practitioners and chiropractors will join primary care providers in getting the inside scoop in the first quarter. Likely next up later 2020 or 2021: ENTs, cardiologists, OBGYNs, gynecologists doing routine care, not cancer care, orthopedists and PTs.
PostPartum Extension: Comedian Robin Williams once tried to convince Hugh Grant and Julianne Moore of his baby-delivering credentials in a classic scene in the flick 9 Months that has relevance today. ‘I was chief of obstruction in Russia….so I know that post pardon deception is very common.’ ‘I beg your pardon,’ Moore winced. Of course, being chief of obstetrics increasingly means you have to understand and help parents prepare for postpartum depression. More insurers are seeing the importance of helping cover services to address it including Empire BCBS of New York, which has lengthened the time for postpartum care from 45 to 90 days under its 2020 maternity services reimbursement policy. Billing is done with CPT code 59430. Other insurers are considering creating 12-month episodes of care featuring 3 months of postpartum services.
Dual Dx No Longer Different: 6 in 10 substance abuse treatment companies are already providing or trying to provide treatment of the whole person and by 2025 it will be rare for these companies to be solely focused on addiction. More of them will also be in some version of risk arrangements with insurers, especially self-insured employers who are already looking for assurances on treatment outcomes. One company, Brandon Electric, told us they are going to do an RFP with 3 regional companies for 1 exclusive slot as the mental health and addiction treatment provider for their 600 employees and their families. The CEO, Brandon Nicols, says they used Shatterproof to help them narrow the list. A recent wave of substance use issues involving both employees and some of their teenage kids prompted the move. Pennsylvania’s Retreat Behavioral Health is one example of the shifting focus. In 2020, they have just added Synergy Health, a treatment division dedicated to mental health. Aetna recognized the company recently for its quality.
Diagnoser Misnomer: While Cigna is urging physicians and other practitioners in its network to start using behavioral health screening and assessment codes, there’s little overall trust and comfort in talking to doctors about depression, our poll found. The 10 codes include a series of G-codes and other codes with recommendations on the type of condition and time you should be taking to diagnose, but screening and evaluating often takes more than just 15 minutes – heck, it can take 3 months in the case of my dad who finally figured out an eating disorder in a young athlete coming in for PT appointments - and it often requires careful nuance in how to get the patient to talk and how to get them to consider the right solution. Physicians, for all their value, aren’t necessarily the right diagnoser-in-chief according to parents. 90%, of 516 polled, said their teens would much rather open up to a teacher or coach than the pediatrician, and they would much rather talk to a friend or even stranger, than their doctor. As for seniors? 56% in our poll say mom or dad most open up to strangers - the person they sit next to at Sunday mass, the home health aide who they’ve never met, or the cleaning staff who come to their home on Tuesdays. Cigna agrees that more of the health system needs to improve how it screens and reacts to these situations.
Radiologists Beware: Artificial intelligence is making its mark on cancer. A study published in Nature earlier this month shows that AI performed better than radiologists when locating certain breast cancers on mammograms. Back in May, Google also collaborated with researchers to show that computers were equal or better than doctors at finding small lung cancers on CT scans. And most recently, brain surgeons started using AI in the OR to help diagnose potential brain tumors during surgery.
Hospice PowerHouse: Humana, which represents the second largest provider of Medicare Advantage plans in the country, acquired Enclara Pharmacia, which provides pharmacy services only to the hospice industry. The deal is expected to close in the first half of 2020 and seems to be another step in Humana’s quest to better control the continuum of care and end of life costs. Humana also acquired Kindred Healthcare (home health) and Curo Health Services (hospice) in the last few years.
Extra Point: So I play Sunday hoops with several Cigna, Aetna and other health plan insurance ballers. It’s old man hoops with a classic Princeton-like flare. Backdoor cuts and pick n’ rolls, fighting through screens and using the glass on a 10-footer, rather than 3-pointer. They won’t let me talk about their missed layups or mysterious muscle cramps, but they are willing to chat about health policy in between games. Not exactly locker room banter, but c’est la vie. This issue features a host of changes from Cigna. Most seem up the fairway but one caught my attention. Former NBA player Chris Herren’s drug addiction is chronicled in the documentary ‘The First Day,’ a film Cigna is promoting as part of an educational program with schools and communities. Horizon BCBS created its own school musical focused on addiction, and others are looking to film as a way to prevent the disease. These are refreshing trends for insurers to support these stories. In my time before writing 24-7 about healthcare, I used to review films and I watched one of the 10 best with my son Tommy last weekend. Coach Carter, which features Samuel Jackson as a coach trying to change the lives of a high school basketball team living in a community where drug dealing and abuse was commonplace. It’s one of the 10 best films ever about losing in sports, partly because it ended with a loss, but also because it showed me that changing behavior – be it in healthcare and physician decisions, or in our kids and parents - requires less emphasis on what is and more on what can be. Here’s that losing sports top 10 review: (https://thebehavioralhealthhour.com/the-lost-column/). Stay tuned, maybe a healthcare top 10 is next…