Jul 6, 2018 | Managed Care Friday
1. 26: Percent of plan premium dollars, according to a poll of 19 regional insurers, that goes to physician services, 25% to inpatient, 21% to outpatient facility care, and 10% to Rx, but pharmacy varies by plan and over the last few years has definitely taken a larger chunk of the total premium dollar, driven by specialty pharmacy cost. Today, the annual trend in specialty pharmacy net of rebates is 15-20% (e.g. the PMPM on total drug costs), say some sources, compared to the 9-11% it was a few years ago, whereas whereas for traditional (non-specialty drugs) the trend is in some cases...
Jul 3, 2018 | Medicare Advantage
Medicare Advantage (MA) is a large and rapidly growing market for providers, and will provide even more opportunities in 2019. CMS will relax its supplemental benefits policies next year, allowing plans to cover more services, including non-skilled home and community-based care and transportation services. More than 21 million Medicare beneficiaries now have coverage through a private plan (which are mostly MA plans), with overall spending of $200B annually. BRG estimates that the number of Medicare beneficiaries in private plans may reach 30M by 2025. Click to read more.
Jun 29, 2018 | Managed Care Friday, Part D, Payers
As a reporter for nearly 15 years and 3 with a community newspaper in Swampscott Massachusetts, it is a difficult thing to hear about the Maryland tragedy. The investigative research team members here are, at our core, reporters, and we all extend our prayers to the newspaper’s family. 1. Where There’s Smoke: People with schizophrenia are 3 times more likely to smoke than other people and tend to smoke more heavily in an effort to control their symptoms related to their mental illness, according to the Mental Health Foundation. Of note, Rhode Island’s BCBS insurer just partnered with...
Jun 28, 2018 | Medicare, Post-Acute Care
Medicare spending often varies significantly by geography, despite a national fee schedule. In 2013, the Institute of Medicine (IOM) put forth a study finding significant geographic variation in spending, with 70% of variation explained by differences in post-acute care utilization patterns. Other organizations including CMS and Dartmouth have come to the same conclusions. Utilizing CMS’s most recent data, this brief contrasts two major cities in 2016, as well as 10-year change in Miami to the national average, to provide examples of these spending discrepancies. BRG analysis finds that...
Jun 27, 2018 | Home Health
CMS has proposed restarting home health pre-claim review in Illinois, North Carolina, Texas, and Florida. The demo is likely to start towards the end of 2018 or early 2019. The program is likely a meaningful administrative burden for smaller providers, but has the potential to improve claims processing for larger providers while reducing scrutiny of industry for fraud and abuse. Click to read more.
Jun 21, 2018 | Drugs, Medicaid, Medicaid Managed Care, Substance Abuse
In its June 2018 Report to Congress, the Medicaid and CHIP Payment and Access Commission made recommendations to change a Medicaid rebate loophole preventing states from paying the lowest price for certain drugs, and to clarify privacy requirements for people with substance use disorder that may inhibit care coordination. The report also addressed the growth of managed long-term services and supports and state coverage of substance use disorder services. Click to read more.
Jun 20, 2018 | Autism, Behavioral
The prevalence of autism spectrum disorder (ASD) has increased over the years, from about 1 in 150 children in 2000 to 1 in 59 in 2014, according to the CDC. While a broader ASD definition and improved diagnosis may explain some of this increase, experts note that a true increase in prevalence cannot be ruled out. Over the past decade, more and more states have required Medicaid and commercial plans to cover applied behavioral analysis (ABA), the leading type of autism service. We expect coverage rates to grow as states continue to expand services, such as New Jersey’s recently proposed...
Jun 15, 2018 | Managed Care Friday
1) 2040: The year when Alzheimer’s disease will consume about 25% of the Medicare budget, according to a new study, aided in part by addiction to smart phones that can cause plaque buildup in the brain, the same plaque linked to Alzheimer’s. Brain scan of people in their 20s showed high levels of buildup due to excessive iphone use. The findings and outlook have implications for policymakers as well as families and employers given the massive direct and indirect cost of the disease. Read neurologist reaction by clicking here 2) Genetic Test Plus: Testing for Cadasil, a hereditary stroke...
