1. 59: The fee in dollars BCBS of Massachusetts will pay for a standard medical tele-health visit, up $10 from last year.
2. OB Pre & Post Term Pay: Changes are likely for OBs both for pre-term and post labor payment. A number of managed care plan case managers, 42% in our poll of 136 of them in January, said they are looking into new depression screening type programs to support moms-to-be, particularly higher-risk pregnancy patients with diabetes or those with prior mental health conditions. The programs may address what one nurse manager called a rise of about 12% in pre-term births due, she said, to undiagnosed depression. OBGYN practices should be able to benefit from these initiatives and work with managed Medicaid and commercial payers across states to conduct the screenings, treat, track and report outcomes. Payment will likely need to be separate though eventually packaged into a bundle. BCBS of Louisiana is looking at post-partem as well, requiring its OBs to submit a claim for post-partem visits using a non-payable code (0503F) so they can track utilization and outcomes. OBs bill maternity care globally, according to the plan.
3. Infusion Pump Policy: Infusion pump criteria is getting a deeper look across health plans in terms of payment policies and medical necessity, in part given rising use of the pumps for a range of needs, including pain, and in the wake of broader discussion about safer ways to address addiction. 71% in our poll of medical and strategic officers at commercial, MA and Medicaid plans noted this.
4. Medicare Advantage Chemo Hurdle: United as of March will require oncology providers to get pre-approval for doing outpatient injectable chemo for Medicare Advantage patients with cancer. The policy impacts providers and patients in Florida and Georgia and then in April rolls out to Wisconsin.
5. Psych In. Babies Out: 58% of rural hospitals in Texas no longer deliver babies. If only telehealth could do the trick, right? Or maybe it could : A maternity nurse in west Texas, Barb Smerson, says she and some former colleagues are thinking of starting a tele, video and dispatch service to avoid situations when families have to drive hours on end to deliver kids. 34% of the hospitals who no longer deliver babies are though pursuing alternative service lines, many looking at adding inpatient psych to make better use of empty wings. Click here for story
6. Conversion: Jerry once accused dentist Tim Whatley of Seinfeld fame of converting to Judaism strictly for the jokes. It did help Whatley with his pre-procedure patient banter so Jerry was probably somewhat right. In healthcare circles, many traditional institutions are facing a conversion of their own but the joke will be on those who miss the bigger picture. A skilled nursing facility in Oklahoma and a hospital in Iowa, both closed due to declining census, will convert to affordable housing, a school, and health clinic for a community in need of all three. These urban-health-social investments are working in a number of communities. United Healthcare is among the organizations making housing investment, enough to help the issue crack the Top 20 managed care priorities. New index here for full analysis.
7. Splitting Medical Necessity: BCBS of New Mexico has new PA requirements for a host of services starting this month, using Evicore some (radiation therapy, advanced imaging, sleep) and managing the rest of the medical necessity evaluations inhouse (dialysis, maternity, neurology, OP surgery, GI, and wound care).
8. Multiple Service Payment Reduction: Anthem and Blue plans are among those now limiting payment on modifier 25 to 50% of the contracted rate when physicians bill it with an evaluation and management service visit. The evaluation is paid at the full contracted rate, but when the same physician does something else for the same patient on the same day billing modifier 25, they will now only get half the rate for this. One contracting manager in Washington on a call this week called this ‘duplication savings’.
9. PBM Play: Regence Blue is using a different PBM this year, changing over to Prime. Home delivery of medications will be managed by AllianceRx Prime, a partnership between the PBM and Walgreens.
10. Extra Point: My mom cheats in scrabble. It’s the closest thing she has to an addiction these days. Like a lot of us, she’s had to deal with a host of behaviors over her 70 some years, not the least of which is my dad. ‘He threw out the social security check again when he was cleaning the kitchen, and now he’s halfway into the outside barrel trying to find them,’ she told me last month. Not sure if she was crying or laughing. Papa can spiral quickly in crisis. He once panicked about not having shaving cream on the eve of a nor’easter, bolted out to the chevy scooter to go to Bill’s general store, and proceeded to back the car right into the lamppost. I still remember helping dad pick up the post and make sure he didn’t electrocute himself trying to fix it. I was 12. I share this story because it illustrates a lot of what we found in our poll of 310 parents (click here), that we love mom and dad, no way do we want them living with us but we do want to help. The fascinating thing is a growing demand among today’s middle age to help the folks get healthcare more easily – like through an app that allows a nurse or physician to come to the home and keep track of those cardiologist visits and medication refills. These apps are now becoming core services of many of the MD-home health businesses cropping up nationwide—those looking to bring us back to Dr. Baker healthcare. In the home. Personal. Low cost. These models, if managed well, and partnered up with Medicare and Medicaid insurers, should thrive. Dad says he likes the home visit at times because he won’t run out of gas on the way to the appointment like last time. He is using ‘the google’ as he calls it for more than looking up basketball drills now. He’s studying up on what he thinks is undiagnosed bipolar (it’s not) and learning about links between nutrition, exercise and mindfulness. Mom says dad spends too much time emailing me. I sort of like it. It’s been a new way to see someone I’ve known my whole life.