35: Percent of Americans who said their financial situation was worse in 2022 compared to 2021, which led to a higher number of people skipping medical treatment due to the cost, according to a Federal Reserve study. Only 75% of families with income under $25,000 reported being in good health, compared with 91% for those with income of $100,000 or more. People most often skipped the dentist, followed by seeing medical providers and filling prescriptions.
Oh, The Worried Well: As Archie once said, ‘why do they always give me a shot where the pain ain’t…?’ It was classic Bunker, worried, agitated and usually offensive. I wonder what he’d make of all the changes in healthcare – urgent care clinics, for one, are more often than not staffed by allied health providers. Bunker only wanted ‘regular doctors’ as he called them and, even though he didn’t know it, he had a bit of managed care in him. ‘Do I really need this um needle?’ he would argue. If there’s one delivery model set to face some competitive turbulence and patient cost adjustments between now and 2025 it may be urgent care. HCA is acquiring 41 urgent care clinics in Texas – 19 FastMed and 22 MedPost clinics in Dallas, Austin, San Antonio, Houston and El Paso. In other urgent care news, Zocdoc has added urgent care clinics to its online platform – the company says urgent care is one of their fastest growing categories. Patients now have 200+ locations across 22 states to choose from.
Pay For Equity: BCBS Massachusetts announced that Tufts Medicine is now a part of the health plan’s pay-for-equity financial payment model. The model ties financial incentives to achieving measurable improvements in health equity. Tufts will focus on reducing inequities in colorectal cancer screenings, diabetes care, hypertension and adolescent well-care visits in their network of 2,300 primary care practices.
Rx Tool: Pharmaceutical analytics company HealthPlan Data Solutions is launching its second product, called RevealRx, to offer payer pharmacy teams a tool that targets members though outreach and streamlines care management. The interface automatically enrolls and disenrolls members, and payers can monitor the data being fed to their case managers to reduce time lost from duplicate calls.
Authorize This: The prior authorization process is considered one of the most time-consuming administrative duties by providers and takes longer to do manually (20 minutes on average) compared to electronically (9 minutes), according to a Council for Affordable Quality Healthcare (CAQH) report. Only about 28% of pre authorizations are processed electronically, though this number has doubled in the past decade and is much higher for things like claims and eligibility and benefit verifications. A bigger question is where the puck moves – for diagnostics, like labs and imaging, there is more authorization for newer generation testing and outpatient diagnostics, but less authorization for certain services considered as cost savers, like the first 3 visits to PT to treat low back pain.
Advanced Care Planning: Cigna is partnering with Koda Health to provide services related to advanced care planning for some Medicare Advantage beneficiaries. Koda’s platform aims to address a gap in coverage around advanced care planning surrounding palliative care, which about only one-third of people make plans for. Cigna plans to expand access to the Koda platform across their MA membership in the future.
Glass Half Full: Cigna is once again delaying their new E&M policy that we mentioned in last week’s edition that would have required providers to submit office notes when submitting E&M claims with modifier 25. The health plan originally tried to put this policy in place last summer but faced significant pushback from providers. Seems like providers have been successful once again.
ER Audit: Starting in September, Highmark will begin auditing emergency claims to determine if the correct codes are billed. The audits, pushed back from their original start date planned for this month, may result in a different reimbursement if the health plan determines the wrong code was billed. We’ve seen several other commercial plans doing pre-pay review of ER coding, particularly level 4 and 5 visits, and it doesn’t look like this trend is going away.
A Richard Kimble Moment: If you are looking to recruit people, link up with local colleges who are expanding their PA and NP programs. About a year ago, a Bay Path College student from Springfield Massachusetts was thrust into helping my dad clean a wound. Dad had pulled a Richard Kimble back home, wrapping a deep shin wound with one hand using amateur tape and gauze like the Fugitive character, driving himself to urgent care in what was a race against time. He had fallen in the garden trying to relocate a hosta only to slip or get dizzy and slam his right shin into a rock. He would later tell me he ‘wanted to get it stitched up before mom found out….’ But the so-called 24-7 urgent care was closed—two of them in fact—so I made my way to dad’s house to pick him up. We averted going to the hospital ER, finding the only urgent care open in the region. The PA, a Bay Path College student, was sharp and a great teacher - cleaning the wound, putting in 8 stiches and allowing dad to feel comfortable.
Extra Point (From The Archives): My kids complain a lot about how I go down the ‘when I grew up’ road way too often and make references to characters like Richard Kimble as though they grew up in the 60s. It’s just so easy sometimes. Helps me make a point, like my latest rant leading into Memorial Day weekend: When I grew up, we ate supper together on Sundays. At 2 o’clock. Not because we were hungry, or it was raining, but because grandma said so. Afterwards, we played kickball ‘til dark. We didn’t have hover boards or Fortnite or Twittergrams or Snapbook. When we fell on the driveway during a game of ‘Red Rover’, mom didn’t rush us to urgent care. There was no urgent care. She layered on three Band Aides and gave you a slice of warmed up apple pie. We didn’t have depression—at least not in the way it’s understood today. Yes, we were sad when the Yankees and Sox were in a rain delay, but dad cheered us up by putting the Polka on the record player and throwing us on his shoulders. We danced. We had a simple life with at most three principles, and I’m pretty sure two of them had something to do with mashed potatoes. We didn’t text or Jabber or FaceTime, we stood by an answering machine hooked up to the rotary dial, replaying Sam’s message because you couldn’t hear the phone number the first dozen times. ‘Download’ was not a word. To hear Survivor’s You Can’t Hold Back, we had to rewind Side B for six seconds, then flip the cassette at least a half dozen times to get to Side A to just the right time. When we were bored, we picked up a shovel and dug a hole, found some worms and put them under my sister’s pillow. Our friends were mostly the seven people we shared the upstairs bathroom with. The same seven we fought with for the Raisin Bran. We wrestled with grandma, played ‘setback’ with papa, and listened to Joe Castiglione call the game on the AM dial. On a good day, I would hold the bunny ears on the RCA, so we could watch the game on TV. What strikes me about then is how if you’re lucky you can get glimpses of this today. Like last weekend, I asked Tommy to lean the phone against the wheelbarrow when we weeded the driveway. We listened to a replay of the inning Fisk waved that homerun fair. We ate spaghetti around two and then played Twister, until the dog peed on the green circle. What’s past is prologue. I would argue that, for some of us lucky enough to be safe and healthy, we aren’t standing still at all as it may seem at times. We are going back, and there’s some good to come from that.