5: The number of new states where Aetna is entering the ACA marketplace in 2022, including Nevada, Missouri, Texas, Florida, and North Carolina. Meanwhile, HCSC will expand its Medicare Advantage (MA) footprint to an additional 90 counties next year, which the company says is its largest MA expansion ever.
Per Member Per Month, And Then Some: A Medicaid managed care plan in Kansas is playing Oz by setting up a series of multi-level payment per month models for youth behavioral health care. In one design, you can get a $1 PMPM for doing follow up calls within 7 days of IP discharge, $20 for each high risk member you see face to face, $0.75 for screening people with schizophrenia or bipolar for diabetes, and $150 for avoiding adverse events. You can share in savings based on a point system, sort of like school where you earn points if hitting performance targets. There is a maximum payout and providers are compared to peers. In another design, the payment is a flat $425 for more complex cases such as youth who have been in the juvenile justice system and also have mental health diagnosis. Incentive payments are made out of a risk pool, with 5% guaranteed and 10% percent earned based on performance on measures like school functioning. One of the gaps in the program in its first years has been a lack of reporting of findings back to families and a lack of a flow of information on progress. “Too many cooks in the kitchen, not enough sharing of information and lack of ownership…..all fixable things but hard to fix without the right incentives,” said Pete Pfau, who’s 15-year-old son was among those treated under the program. His son is now 18 and out of residential treatment but needs significant services.
Inflection Point: Effective January 1, 2022, Regence will make Inflectra its preferred infliximab product, and coverage for all non-preferred infliximab products, including Remicade, Renflexis, Avsola and Ixifi, will require additional approval. Members who are currently on an infliximab product other than Inflectra will need to transition to Inflectra on or after January 1, 2022.
Union California: Kaiser and Providence are partnering to build a new medical center in California’s High Desert region. The new hospital, to be located in Victorville, will be jointly run by the two very different health systems, and patients of both will be able to receive most services. However, Kaiser members won’t be able to get certain reproductive services at the hospital, including abortion, because of Providence’s Roman Catholic affiliation.
Sleep Time: Some commercially insured members at a handful of health plans starting in October will require prior authorization for lab-based sleep studies. Home-based sleep studies for Commercial members do not require prior authorization.
Quarterback Risk: New quarterly reports for Medicaid and Commercial Episodes of Care will be available starting next week and so-called quarterbacks – those accountable for taking the risk for costs incurred during these episodes – do not have to make a payment back to BCBS of Tennessee in the event they owe risk-sharing payments.
Expensive Genes: Beginning this month, Cigna is expanding its Gene Therapy Program to also include advanced cellular therapies, such as CAR T-cell therapies. Cigna introduced the program in 2020 to help manage the quality and affordability of these novel, expensive therapies. The program steers members toward high quality health systems who have chosen to participate. Recent provider additions include Children’s Hospital Colorado, Connecticut Children’s Medical Center, and Morristown Memorial Hospital.
Imaging Off-Site: Starting in September, Cigna is expanding precertification requirements for CT and MRI scans to include a site of care review for all members covered by self-insured plans. All commercial Cigna members will now have to go through eviCore to make sure imaging is being done at the lowest appropriate level of care. A hospital outpatient setting will only be covered if an alternate site is not available.
Pharmacy Swing: BCBS Texas has new preferred specialty and mail order pharmacies for its commercial members, effective August 1st. Following several other managed care plans, BCBS TX will move to Accredo for specialty and Express Scripts for mail order for all commercial members whose pharmacy benefits are managed through the PBM Prime. Medicare Advantage members will have these vendors as additional options but are not required to use them, at least for now.
Extra Point: It’s not enough to be talented. I mean there’s a lot of talent out there, but it’s owned by lazy, stupid or essentially boring people. You can’t just be talented. You have to be terribly smart and energetic. You also have to become necessary to people, by working hard and bringing more than your bones and your skin to the project. Don’t just show up. Transform the work, yourself and everybody around you. Be needed. Be interesting. Be something no one else can be – and be it consistently. This hung from a tack board on the third floor on Hereford Street last week, a classroom building Sophia and I toured during her first college visit to the Boston Conservatory of Music. Most of the kids just ambled by to the next tour stop. I fell back along with this guy Fred Hallen from NYC. His granddaughter was interested in the school and there he and I were, total strangers, staring at this Katherine Hepburn classic. Fred turned to me and said – “You know I’m pretty smart and I work hard and bring a lot to projects….but I don’t have a lick of talent….” Then he laughed like a bear probably laughs. Talent is probably overrated, I said, but sometimes it sure can’t hurt. In healthcare, I imagine the most talented are those behind the curtain creating diagnostic and treatment advances, or cardiologists and anesthesiologists who need a steady hand. I might argue that talent is less important for many on the frontlines – that the singing nurse who shows up every day to care for the older lady alone at home is being exactly what Hepburn called for. Needed. Interesting. Consistent.