$2.2 Billion: The estimated price tag for the first CRISPR gene-editing treatment for sickle cell disease approved by the FDA last week. But health systems, health plans, employers and patients all face potential challenges in paying for the potential cure. ICER says the price tag may be justified compared to the cost of lifelong treatment, but paying for a lump sum of that size all at once is something our healthcare system has been struggling with how to handle as more and more high-cost gene therapies continue to be approved.
4th & Goal: Tom Brady may be able to find new work. We talked to 6 medical directors for behavioral health this week in a series of in-depth interviews – each of them interested in pressing psychiatrists and psychologists to “get to a goal, because many aren’t,” and likely rolling out new policies, including reimbursement adjustments tied to performance.
At Home Pediatrics: Nemours Children’s Health plans to be the first children’s hospital to launch a pediatric hospital-at-home program. The program, intended to launch in 2024, will enable Nemours to provide care for more patients when its hospitals are at capacity, and will provide acute care to patients within a 40-mile radius of the health system’s hospitals in Wilmington, Delaware and Orlando, Florida.
Domino Effect: Carelon, formerly known as the benefit manager AIM Specialty, is launching CarelonRx Pharmacy. The digital pharmacy will offer text and phone support between pharmacists and patients, easier comparison of drug prices and a Dominos’ delivery style tracking update for delivery prescriptions.
Take A Left After The Cereal Aisle: Kroger, a supermarket chain that operates 225 in-store healthcare clinics, announced a shift into primary care for seniors. Kroger Health will transition eight of its “The Little Clinic” sites to focus on senior care. The senior care sites will try to take a more value-based approach and offer longer appointments with nutrition counseling and medication review. Fellow retailer Best Buy also continues its push into healthcare, this time partnering with remote patient monitoring firm Biobeat. The company will integrate Biobeat to boost its home care offering.
Buy & Bill Lives On: Effective February 2024, Highmark BCBS will eliminate its “mandatory” category for medical injectable drugs, which had required providers to go through an assigned specialty pharmacy for 36 drugs for its Medicare Advantage patients. Once the change goes through, providers can buy and bill these drugs or choose to use a specialty pharmacy, though the particular pharmacy will still be assigned and not up to the provider.
Steering Wheel: Empire BCBS, an Anthem plan, is launching a new High Performing Provider (HPP) designation for providers who meet certain cost and quality metrics. Effective February 1, 2024, HPP designated providers will be promoted in a number of ways, including member searches and when members call for referrals.
Menopause Support: The virtual mental health company Talkspace announced a partnership with digital menopause care organization Evernow to help women who experience anxiety, depression and hormonal shifts throughout the menopausal period, which can last 7-14 years. There are efforts at a federal level to support virtual psych. The Home-Based Telemental Health Care Act, a new bipartisan bill, aims to boost access to virtual mental health services for rural communities by authorizing grants of up to $10 million until 2027.
Extra Point: So apparently I’m turning to the health insurance community for help raising my children. A collection of unions, health insurers, and Medicaid and Medicare plans are starting to use predictive analytics tools to target patients at high risk of a painful event like a fall, a myocardial infarction, COPD exacerbation or suicide. What’s interesting is several are doing this by looking at patterns of behavior, not by diagnosis – like trips to three specialists inside three months, the daily average consumption rate revealing an early or late prescription refill, a series of missed appointments. The insurers will then deploy peer navigators to help fix the behavior. This is a good trend I may try at home – our youngest, 17-year-old Tommy, seems to have these patterns of forgetfulness. My wife says it’s his way of making a mark as the last child – leaving half-filled red Gatorades in the bathroom sink – like literally in the sink – discarding gummy wrappers in the tub, putting his stinky tennis socks in the stove, baking at 350 because “doesn’t everything cook at 350,” then leaving the kitchen. R41.3 is the technical diagnosis code for forgetfulness, but I’m inclined to follow the health insurer lead and use predictive analytics, aka cameras. The problem is there is apparently no good treatment. My wife says the solution is really to just “wait it out.”