18: The percentage of Americans who have skipped a medical appointment or filling prescription drugs in the past six months because of financial strain, according to a new NPR/PBS Newshour/Marist poll. The percentage of respondents answering yes to these questions was higher among those with lower incomes. 30% who make less than $25,000 a year said they had skipped a medical appointment or prescription in the past six months, while 21% of those who made $25,000 to $50,000 a year answered the same. Just 9% reported delaying or skipping paying medical bills or insurance costs in the past six months to save money.
Back To The Future: The kids like to say I need to join the 21st century, and commercial payers do too, or so it seems. Starting in October, several big payers nationally will update commercially contracted rates that have been based on older years of Medicare such as back to 2007 or 2015, or 1998 in one case. Rates will be adjusted to either the current Medicare year or a more recent year, like 2020, based on CMS’s relative values. We talked to physicians who are in the “procedures” side of healthcare, and they are “definitely impacted,” most were notified earlier this year or this summer. You can challenge the changes but “we were not successful” one urology administrator said, and while providers do not need to sign the contract amendments, most will, given the market size of the payers. “If we don’t sign, we probably lose a lot of patients to other providers.” Some payers said these changes will be rolled out by the end of the year. Typically, it takes commercial payers between 9 months and 2 years to adopt Medicare changes – usually at a lag and not at the same level but “this one is more impactful” because it adjusts the payment year. Lab providers between 2016 and 2018 had to deal with similar adjustments when many commercial plans adjusted their rates to tie to the current year of Medicare “to make it easier on the ancillary contracting teams.”
Pre-Approval Waived: Like the dads who do just enough dishes and laundry to get to golf Sunday mornings without mom’s pre-approval, healthcare providers are finding insurers more amenable to allowing services without pre-authorization (PA). The “Texas gold card bill” takes effect October 1, reducing PA requirements for certain in-network physicians and providers. Gold card programs have been utilized by managed care plans for more than two decades, but Texas was one of the first states to implement a program into law. For a provider to receive a gold card, Texas payers will analyze approval rates for at least 5 PA requests and if the provider receives at least a 90% approval rate then they will be exempt from PAs for that service for 6 months until the approval rates are re-analyzed.
Early Anxiety: A year removed from the U.S. Preventive Services Task Force recommendation for people to get colorectal cancer screening starting at 45, the task force is now recommending providers screen all adult patients under 65 for anxiety. The advisory group said their guidance is intended to help prevent mental disorders from going untreated. Though COVID-19 certainly increased stress and anxiety for many, the group said they had been preparing the recommendation before the pandemic. In a poll of providers, 64% of PTs and 59% of imaging centers say their patients are now more commonly alerting them to their anxiety. “Perhaps stigma changing for good,” said Paulette Connors, a physical therapy from Massachusetts who says it helps to know if patients have anxiety, particularly for treatments like traction or for nerve related conditions.
Digital Health Benefit: Gravie Partners, a health benefits company, is adding digital health options for all their member plans. These will include digital fitness apps FitOn and Peerfit, digital PT program Sword, as well as telehealth app Teladoc, all at no extra cost. These services were chosen based on members’ claims data which showed mental health and musculoskeletal treatments were most needed.
Penn Pals: The University of Pennsylvania Health System is investing in Independence Blue Cross’s subsidiary, Tandigm Health, which focuses on preventive primary care. This will be a long-term commitment from Penn Medicine to work with Tandigm for all primary care value-based programs across all payers, set to launch in 2023. Penn will add 275 of its primary care doctors and an additional 100 advanced practitioners to the 400 PCPs in Southeastern Pennsylvania who already have contracts with Tandigm. The practice currently helps manage the care of 110,000 individuals for its doctors and Penn will add about 200,000 patients to that pool. Independence and Penn Medicine have a history of collaborating around value-based care, including the launch of a program in 2017 that reduced hospital readmissions.
Extra Point: Mike once told Archie in All In The Family, “Hey Arch, would you stand up and cheer if it was me at the door?" “Well that depends Meathead – on whether you were comin’ in or goin’ out?" Last I checked there’s a monthly premium for the “family” and 5 names are listed on that insurance card, but where in the world is the health plan? We often think about the total cost of care in personal terms, but there’s a family cost. 47-year-old Jenny, a former swimmer, develops alcohol disorder in her early 20s. An assessment by a physician reveals significant childhood trauma and some more recent abuse, but also a larger family health crisis. No longer all that mobile, Jenny has hypertension, fibromyalgia, needs a walker, barely can get to the mailbox, takes Effexor for anxiety, Xanax, and a beta blocker Metoprolol. Her PCP is absent, giving her 90-day refills on these drugs, but doesn’t follow up. She’s now type II diabetic, approaching obesity, and suffers insomnia. But Jenny carries on - she tries to take care of her 80-year-old mom and her younger son Alex who is on the autism spectrum and deals with GERD and sleep issues, but she struggles with it all, obviously, entering him in a full-week ABA program. She cooks for her husband Ben but their health as a couple and as a family is waning. Ben is fatigued, starts drinking himself, and is missing work to help out with Alex and his mother-in-law. Their dog Suzie is no longer walking. So where's the health plan? Who to prioritize, and how? A medical at-home model emerges, focusing on the full spat of mom’s conditions, helps Jenny get sober after in-home detox then moves to addressing other issues, reducing doses, treating her childhood trauma, getting mom more mobile. Alex now doesn’t spend all week in ABA and starts to play in a specialized soccer program and helps mom make supper. The medical team works with Alex and Jenny to address their insomnia and mom and dad re-engage in a healthier marriage, walking the dog and cheering for Alex at games. The plan takes 9 months. The estimated $500,000 in annual spend in prior years drops to just checkups. The story may be an extreme one but it’s more common than you may think, and it illustrates what managing care for a family in crisis can look like. When building your model or raising your family, take note. Where’s the doctor? Are they in another state or building or center to the assessment and care—are they comin’ in as Archie said, or checked out as Jenny’s PCP was—and are you capturing and trying to solve just one person’s condition, or have you thought about how you can solve the family’s?