20: The percent of current prior authorization requirements United announced it will roll back beginning in the third quarter of this year. Beginning in early 2024, the insurer will also implement a Gold Card program for eligible provider groups that would eliminate prior authorization for many procedures. Keep in mind that for some services, like pain management, even if the health plan doesn’t require pre-approval they likely still have coverage criteria and step therapy rules to follow.
In Prison: Ventura County of California is finally opening a mental health unit at the Todd Road Jail after almost a decade of efforts to treat inmates with serious mental illness and medical conditions. The health unit is a 64-bed locked facility with medical treatment rooms with the capability for x-rays, dental check-ups and dialysis. The presence of people with mental illness in jail is a longstanding issue – the local sheriff’s office reported that 40% of the total jail population takes a medication for a psychiatric disorder.
Latino Resources: Zócalo Health, a virtual healthcare company that provides primary care services and mental health support to Latino patients in Texas and California, is partnering with the Mark Cuban Cost Plus Drug Company to expand its members’ access to lower-cost prescription medication. 1 in 4 Americans taking prescription drugs say it’s difficult to afford their medicines, according to the Kaiser Family Foundation. All users of Zócalo Health will have access to Cost Plus Drugs’ prescriptions through membership packages or urgent care visits.
Smash Stress: If you’re in the mental health field, consider partnering with Hope Means Nevada, a suicide prevention nonprofit that’s now partnering with Anthem to host a “Smash Stress” social media campaign to raise awareness of mental health issues for teens on Facebook, Twitter and Instagram. Teens will be encouraged to log onto social media daily to learn about stress-relieving techniques, as well as how to balance school tasks, have a healthy body image, and find a therapist.
Predicting Outcomes: Advocate Aurora started a 12-month pilot with predictive analytics company KelaHealth aimed at improving surgical care outcomes. The platform uses clinical data and AI to predict patient risk and integrates with the EHR so Advocate providers can see in real time a patient’s risk before and after surgery. KelaHealth’s founder says the company so far has only worked with health systems, but may pursue payers.
Facility Fees: Many hospitals are continuing to charge “facility fees” for things like outpatient procedures and even telehealth visits. Hospitals say they need the fees to cover infrastructure and staffing costs, but at least five states are considering laws to prevent these fees from being charged for certain services. A 2022 RAND report found that facility and related professional fees resulted in employers and private insurers paying 224% more than Medicare would have paid for the same procedures at the same sites.
Let’s Go Mets: The New York baseball team is partnering with NewYork-Presbyterian to “promote health and wellness” in their communities. They plan to hold cancer screenings, blood drives and wellness experiences, some at Citi Field. And beware if you’re an expecting Yankee fan – as part of the partnership, people who deliver their babies at NewYork-Presbyterian hospitals will also be treated to a Mets onesie.
Extra Point: Nebraska Internist Marvin Bittner once told me he ended up buying one of those imaging vouchers through MDSave to cover an MRI his doctor thought was necessary to identify suspicious areas for targeting during a prostate biopsy. And who said doctors weren’t cost conscious? I told Dr. B that using any sort of voucher is usually trouble – I should know, I used one I found in an ATM vestibule to pay for the limo that never showed up on my wedding day. Still haven’t lived that one down! The night before Dr. Bittner’s scheduled MRI Aetna called to deny the scan, arguing his results didn’t meet coverage criteria. Bittner says his doctor was ‘using judgment’ after a series of suspicious PSA results. For what it’s worth, clinicians we talked to in the UK say they routinely do prostate MRIs before these biopsies. But rather than leave Dr. Bittner fledgling in the wind, the hospital where his doctor works told Bittner to buy an MDSave voucher to cover the MRI at a cost of about $150 less than he would have paid for the deductible had he submitted the claim to Aetna. The story ended well. No cancer. But it illustrates some oddities: (1) A US insurance company not covering something that the UK National Health Service does cover, despite its reputation and (2) The MDSave Groupon-like voucher for the entire MRI coming in at a lower cost than a deductible.