1.8 Million: The number of people who received an updated COVID vaccine the week ending September 22. The number isn’t as high as many health professionals hoped, likely due to some glitches with the rollout and lessened demand. The cost for COVID vaccines has also switched from the government over to commercial insurance plans, possibly leading some to forgo the shot due to worry about potential copays, though health plans are not allowed to charge.
Let The Drug Price Tactics Begin: Medicare Advantage insurer SCAN is getting ahead of the government's planned drug price negotiations by offering seniors free or $11 monthly co-pays for 13 name brand drugs starting in 2024. SCAN selected cardiovascular and diabetes drugs with no generic alternative, which means they are often more expensive. Currently, SCAN members have copays ranging from about $30 to $50 for these drugs. Additionally, none of the medications will have prior authorization requirements.
Nursing Home Flip Flop: Louie DePalma of Taxi TV fame once said nursing homes are a great deal except that they probably spend too much on meals, arguing that the resident’s memories are so bad “they don’t know whether they had 3 meals or a cracker.” Louie was harsh at times but nursing homes today tend to agree given the high proportion of dementia and the high amount of food waste. “Acuity going up, cognitive issues more pronounced – it’s a hard age to manage,” Paula Kane, an administrator told us. Health insurers agree and are increasing scrutiny of SNFs. Carelon—the benefit manager for Anthem and others— will begin managing post-acute care for Regence BCBS’s Medicare Advantage members in 2024. They will begin requiring preauthorization and reauthorization for home health, SNFs, LTACs, and inpatient rehabilitation. On the flip side, as of October 1, BCBS Minnesota no longer requires prior authorization for any commercial members who need skilled nursing visits, likely due to a high rate of approvals.
Transport Inside: Speaking of taxi rides, the transport industry continues to evolve. Back in July, Arkansas BCBS ended its contract with Alacura Transportation Benefit Manager, moving ambulance network operations internal and distributing commercial contracts to ground ambulance providers. These providers are now no doubt competing with the ride-share companies. Lyft Healthcare’s Buck Poropatich said in our interview last year that its fleet of drivers lowered ER visits 40% by bringing people to doctor’s offices or OP visits. “We don’t need wheelchair-accessible vans going to pick up somebody who’s appropriate for rideshare,” he said. Franciscan Health System in Indiana at one time selected Uber as a service to transport its Medicare seniors to appointments and from hospital to home as part of its accountable care organization, according to business development director Sean Duddy. Rideshare-based non-emergency medical transportation does not require any specific healthcare-related training for their drivers, Poropatich said, but driver education on identifying mental health crises and then responding to them is likely to become more important in the future. For instance, how many drivers know the difference between a panic attack and heart attack? Panic attack symptoms include chest pain, a racing heart, and sweating, which are three of the same symptoms common in those having a heart attack.
Go Blue: BCBS Michigan is partnering with supercenter chain Meijer to offer a co-branded Medicare Advantage plan. It will include $0 premium and $0 copay on many generic drugs along with an annual allowance of $660 that members can use at any Meijer center in Michigan to purchase health-related items or healthy foods. Medicare plan Alignment Healthcare has also developed a food-focused product that will be available in 13 California and Nevada counties with benefits like a quarterly stipend worth up to $100 that can be used for Instacart purchases.
Nutrition Boost: Horizon BCBS is updating coverage of nutritional therapy effective November 2. The health plan currently only covers nutritional support if enteral nutrition comprises 100% of an adult member’s daily caloric needs but next month coverage will be extended as long as enteral nutrition meets at least 50% of caloric needs.
Last Off The Bench: Aetna began requiring prior authorization for Eylea October 1, 2023. Many insurers have already moved in this direction and promote Avastin first with no pre-authorization and, in some cases, require patients to fail on Avastin before being allowed to try Eylea or Lucentis.
Virtual Care Hiccups: For the second year in a row, Bicycle Health, a virtual opioid treatment provider, had to fly in providers to see patients in order to continue their access to OUD treatment. An Alabama law passed in 2022 prevents providers from writing prescriptions for controlled substances without an in-person visit so Bicycle Health coordinated the “Alabama Airdrop.” Nearly 300 patients were seen in-person over 6 days which will allow them to continue receiving treatment for another 12 months. Other virtual health providers are dealing with a decision by one of the leading US insurers to halt coverage of virtual IOP. There has been some talk inside insurers about how to address growing mental health spend, up from 1% to 6-8% of total medical in many cases, and reconsidering policies for long virtual sessions with unclear outcomes is thought to be a target. It will be interesting to see how many other insurers follow suit.
Extra Point: Ironically dad’s 9th fall leading him to the hospital ER had nothing to do with being orthostatic, not drinking enough water or the effects of vertigo and a heart surgery, but because the darn cell phone range so loud he jumped and slipped. About 24 hours before the fall, he emailed me with a problem. “BRY!!!! PHONE ISN’T WORKING. IT HASN’T RUNG IN 2 DAYS. YOUR MOTHER PRESSED THE PHONE BUTTON REALLY HARD BUT IT DIDN’T WORK!! NO RINGS!!! DID YOU WATCH THE GAME? THE PATRIOTS STINK!!! CAN YOU COME BY TOMORROW TO HELP?? LOVE TO THE KIDS.” It’s ironic that for years the folks resisted the cell phone and after a few short months have come to rely on it more than bran muffins and the newspaper word jumble. Ironically, it turns out there was nothing wrong with the phone at all – it’s just that only 4 people know their number.