1. 50.7: The percent of women in medical school, up about 3% since 2010. There are about 21,000 enrollees today. Two of my three kids want to be physicians – one boy and one girl. The boy wants to be a dermatologist or doctor of physical therapy, having spent a good part of his freshman year in PT. The girl wants to be an APRN or family doctor back in her home country of Thailand. In either case, neither solve the physician shortage on their own but in a straw poll of 38 medical directors this week, 37 said the girl gets their vole for ‘adding more value’. If you are looking at investing in global healthcare, perhaps that’s a clue; if you’re in PT or dermatology, take the poll with a grain of salt.
2. MA Reimbursement Change: In May, United Healthcare will change Medicare Advantage reimbursement policies for professional and technical services including lab testing to better align with its Medicaid and commercial plans. Details to follow.
3. Autism Therapy Reaction: The first ‘breakthrough therapy’ medication with potential to improve core symptoms of autism has been approved by the FDA. Roche’s Balovaptan improved social behaviors during clinical trials. A question for all autism therapy providers, namely those focused on applied behavioral analysis, is where these medications fit into healthcare delivery and how managed care may position them relative to ABA and PT/OT/ST services. ‘I think it’s all on the table – we’re heavily focused on ABA now and network development but in the next year or two we’re looking at diagnostics in this area as well alternative treatments – would like to see us develop pathways to help the referring providers and schools on what makes sense, so parents are scrambling for 2-3 years to find the right treatment plan,’ says Martin Flanders, MD, who serves on several BCBS behavioral health committees.
4. Genetic Utility New #1: Regence BCBS, this spring, will implement a number of significant utilization management changes for transgender services, chronic pain stimulation and its #1 focus, genetic testing. These will continue to be services the plan monitors closely. For example, genetic testing for Li-Fraumeni syndrome is now considered necessary under certain criteria but when evaluating the utility of genetic panels the plan decided to add 18 new investigational panels and remove 61 others. New genetic technology has led to the ability to examine many genes simultaneously, resulting in a proliferation of genetic panels. The intended use for these panels varies: for the diagnosis of hereditary disorders, a clinical diagnosis may already be established, and genetic testing is performed to determine whether there is a hereditary condition or to determine the specific mutation. In other cases, there is a clinical syndrome (phenotype) with a broad number of potential diagnoses and genetic testing is used to make a specific diagnosis.
5. Obesity Treatment Skepticism: Delaware’s Medicaid program starts covering obesity treatment sessions in 2019 – in our poll of PCPs on the topic, 82% of physicians who see Medicaid beneficiaries are skeptical, saying they regularly discuss nutrition, weight and healthy lifestyle as part of wellness and sick visits and most believe these so-called obesity treatment sessions would be better if ‘out of the office setting’. ‘Getting paid specifically for this may work, but it seems odd to separate it out into its own visit and code,’ says Marsha Heller, APRN. ‘Why not a single case rate that covers all the issues as part of the evaluation or why not pay us or others to do true obesity prevention or intervention with those of any age who need more activity?’ With Medicaid patients, Heller says part of the challenge is at least half of her pediatric population struggle to have enough food in their home, much less healthy food. ‘Had a student in today who is having recurring muscle and pain issues and keeps taking ibuprofen – she just needs bananas.’
6. Izzy Mandelbaum Healthcare: This Seinfeld icon once barked at Jerry that ‘it’s go time’, a plea from the Lloyd Bridges character for the weaker, unhealthier comedian to shed some pounds. Managed care organizations are in a bit of their own go time these days, more willing to entertain contracts with medical groups offering a new site of care. One managed care medical director in Indiana is talking to a medical group here that is turning an old apartment building into a basketball court and gym for patients who need more activity – office visits, check-ups will take place at the facility. The health plan, Welborn, would try to pay the group a PMPY to track BMI, obesity and other measures, including presenteeism in school and work. ‘This is the sort of thing that gets my attention – rather than come in saying you want a 10% increase because you added a clinic, show me how you’ll change the course of life for these patients’
7. Diabetes Glucose Monitoring: Washington State’s Health Technology Clinical Committee reviews evidence and recently found that select use of continuous glucose monitoring was as safe and clinically effective as alternatives for some diabetic conditions. The committee recommended coverage for Type 1 and Type 2 adolescents and children unable to achieve target HbA1C despite adherence to their prescribed glycemic management plan. Other recommendations included coverage for certain pregnant women. Final coverage decisions will be made this year.
8. Prior Authorization Round-Up: Aetna, starting this month, requires pre-approval for dental implants and dialysis visits performed at non-contracted facilities, as well private duty nursing in select situations. Contact us for details.
9. Extra Point: Patriots by 6.