35 Million: The number of prior authorization requests submitted to Medicare Advantage plans in 2021, about 6% of which were fully or partially denied. But good news for those who take the time to submit appeals - ~82% of the appeals ended up being overturned. Anthem had the highest number of PA requests per MA member in 2021, followed closely by Humana and Centene. But submitting and appealing prior authorizations takes time and energy and is likely contributing to provider burnout. A study from Medscape showed that more than half of physicians report feeling burned out and nearly 25% feel depressed.
Autism Adjustments: Premera BCBS is making some changes to its ABA policy, effective May 2nd. The Washington insurer is expanding the type of providers who can diagnose autism and provide ABA services, likely in an attempt to expand access to these services. A diagnosis can now be made by any “healthcare professional whose legally permitted scope of licensure includes diagnosis of psychiatric disorders or neurodevelopmental disorders." Premera also updated requirements for where ABA can be delivered, now including community settings and schools.
Feeling Blue?: North Carolina’s Blue plan will begin insourcing behavioral health referrals in April, replacing the vendor they’ve been using, Quartet Health. This follows the health plan’s trend over the past few years of focusing on behavioral health internally – by bringing the referral process in-house, the plan “will have a stronger, holistic view of member health needs.” They are establishing a team of care navigators within the Behavioral Health Care Management division who will work with members seeking care and the behavioral health specialists providing it.
La La Land: Payers are getting creative in how they are addressing the growing mental health crisis among children and teens. LA Care and Centene are partnering to offer free mental health services to 1.3 million public school students in California. This program is backed by school-based telehealth company Hazel Health and will be optional for all local school districts, but Los Angeles Unified School District and Compton School District will be the first to use it.
Oncology Drugs: Mark Cuban’s Cost Plus Drug Company is now partnering with cancer care support company OncoPower to offer oncology drugs via its Medication Savings Suite. The platform will be integrated within OncoPower's Pill Reminder Tool, which alerts patients of cheaper generic options available through Cost Plus Drug when patients log a new medication into the tool.
Only The Lonely: Social isolation is associated with a 50% increased risk of dementia according to the CDC, so more companies are trying to address loneliness and insurance is showing some willingness to support. A senior-focused virtual reality company is now covered by MA plan AgeWell in New York. My parents said they barely know how to turn the TV on so the idea of operating a headset seems “a bit above our paygrade,” but there is some evidence that these systems can work. The virtual headsets from MyndVR are designed to aid older adults with feelings of isolation, anxiety and depression, and promote memory stimulation and socialization.
Tier 1: United Healthcare recently expanded access to NexusACO plans, a commercial tiered benefit plan designed to encourage members to seek care for Tier 1 health care providers, including incentives such as lower copays. NexusACO offers two plans, one that requires referrals and one that does not, all members must choose a PCP to manage overall care.
Extra Point: My daughter left a stack of dirty plates outside her room last night like you might at a hotel. The dog licked them clean and even brought one to the kitchen. “Would you like the turn-down service too?” I quipped. “I have 2 tests and a quiz tomorrow for the second time this week,” Sophie lamented with that bashful face she knows I cave to. Maybe we need one of those tins that lab offices use for specimen pick-up. Like schools, the healthcare system seems to order a lot of tests, and the question is how many are actually necessary? A poll we did a few years ago found that the clinical utility of lab tests varies – that maybe 20-30% of the time physicians are ordering tests they probably don’t need to. Nine out of 10 health plan medical directors argue that the utility of lab testing will likely become clearer and more important as more physicians take risk—noting that with more at stake, physicians will demand more from the test result or report. Asked to weigh how much of the time lab testing is helpful today, cardiologists and endocrinologists we polled say that lab testing helps ‘validate what they're doing or plan to do’ for about 43 out of every 100 patients on average, redirects or actually changes their treatment approach for one-third of patients, and is inconclusive or useless in 15%. For “high-risk patients lab testing doesn’t add much info for me,” one doctor said, and “borderline hormonal tests (like metanephrines, cortisol levels) are more confusing than helpful,” another warned. On the other hand, testing is very helpful to figure out fatigue in undiagnosed hypothyroidism or “when a BNP level redirects appropriate use of a diuretic.” I asked Soph about her tests on the way to school. “You ready?” She shrugged and said, “if by ready you mean do I know the structure of the judicial branch and how to conjugate verbs in French, it’s a 50-50 shot.”