49: The percent of Medicaid, Medicare, and commercial payers who named this their top priority for 2021 in what is a bit of surprise but an indication of how the health system continues to evolve. The new #1, the full Top 20 priorities and what moved up and moved out since last year will be reported in the 15th edition of the Healthcare Payer Index coming out soon. Stay tuned.
Alternative Pay: 31% of surveyed payers say they are thinking about the next generation of payment models and one model, likely developed by some insurers, will target severely mentally ill populations. But creating the right model, price, incentives, and PMPM, as well as finding a network provider able to have success is going to be difficult given the significant variation in patient diagnoses and needs, from schizophrenia and bipolar to eating and panic disorders. Still, in 2021, expect more insurers to tackle these alternative concepts and either pilot or partner with a kind of care management company able to manage treatment, avoid hospital cost and improve quality of life.
Anesthesia Cometh In: BCBS of Texas and U.S. Anesthesia Partners signed a four-year agreement that allows BCBSTX members to continue receiving services from the national anesthesia provider at in-network rates. The agreement covers more than 2,500 clinicians in Texas and expands the relationship to include BCBSTX Medicare Advantage members.
Crowded House: If you’re a fee-for-service primary care practice in Louisiana, South Carolina, Ohio, or North Carolina, get ready for a new value-based competitor to come into the market as Oak Street is expanding their footprint into these states in 2021.
Specialty Pharmacy Integration: Centene plans to acquire PANTHERx, a specialty pharmacy focused on rare diseases and orphan drugs, by the end of the year. PANTHERx will operate independently as part of Centene's Envolve Pharmacy Solutions, their drug management program that includes PBM services and specialty pharmacy solutions. This is another example of consolidation in the specialty pharmacy space, as several payers in recent years have acquired them or formed exclusive partnerships.
Surgical Stake: Tenet Health signed a deal with SurgCenter Development to acquire up to 45 ASCs across nine states. The centers will be operated by Tenet’s ambulatory surgery unit, USPI, and will bring their total number of ASCs up to 310. Tenet will have up to a 60% ownership stake in the centers, with the rest owned by physician partners.
Humana Expands Value Models: Humana has been busy over the last month, announcing new expansions, partnerships, and a new value-based model. First, Humana is strengthening its value-based partnership with Vancouver Clinic by opening a second neighborhood clinic, Evergreen Place, in Washington. Like their previous venture Vancouver Plaza, this one will feature a mix of providers and will offer preventive care and telehealth services to all Humana Medicare Advantage members, along with Humana Dual Eligible members. The health insurer also signed a new agreement with Prime West, effective January 2021. Under the agreement, Humana MA members in Nevada who pick a direct network option will have access to an additional 120 providers at 42 Prime West locations starting in January. Last but not least, Humana is launching a new primary care value-based model called Primary Care First for MA members in HMO and PPO plans across 48 states. It will build on the CMS model.
Gene Therapy Payment Model: Earlier this year, we published a report on the ways payers are trying to address the high cost of these treatments. Check it out here.
Extra Point: Maria Sanchez has had a tough go of it this year, losing her parents to COVID and her 51-year-old husband, a factory worker who didn’t get to his doctor quick enough this year and missed an early diagnosis of cancer. But on Thursday afternoon, after a 12-hour shift at a Hartford hospital, Maria, a nursing aide by night and mom of two by day, hopped off the 62 Bus line, maneuvered through a few slush puddles and saw her kids doing snow angels out in front of their apartment building. Jayla, just 5 years old, and Xiel, 12, don’t quite know what loss feels like to their mom but they know mom has been sad. Maria walked over to the kids and started crying. “The kids haven’t had a chance to just be kids much this year.” Xiel has become the man of the house this year – shopping, cooking, and taking care of his sister. Internet is spotty here in the four-story building, often making it difficult to be online for school, so Xiel has relied on a neighbor to help him with reading and writing. “He’s so smart but I worry about all that I put on him.” Maria wiped away her tears with her mismatched mittens and dropped her backpack into the snow and fell backwards into snow angel position. Jayla jumped on her and giggled. “Ma ma, I love you – can we have hot cocoa?” Maria smiled and exhaled all at once. It’s been a tough year for sure, but moments like these give her hope. -BC