1. 80: Percent of non-emergent air ambulance transports, up from 64% last year, that will require pre-approval starting this year, based on a poll of 62 different health plans. There’s a hidden benefit: payers using the authorization process to intercept the next level of care (i.e. hospital or SNF) and diverting to a different option, if lower cost and better quality.
2. No More Reimbursement: Screenings are in and counseling out under a new Aetna policy taking effect this year. The MCO no longer reimburses evaluation and management services billed by some medical specialties, including alcohol and drug counseling, marriage/family therapy, and crisis diversion. Aetna still reimburses structured screenings for alcohol and substance abuse (e.g., AUDIT, DAST), and brief intervention services. Check code 99408-09 if you’re in this field.
3. Top 20: HIV jumped into the top 20 in the latest Managed Care Investment Index, one of eight new entrants since last December to crack the poll of payer priorities. Emergence of generic options is giving managed care an opportunity for savings for the first time in what has historically been an unmanaged class. While it will give payers a chance to save, and likely hurts branded drugs, specialty pharmacies could benefit by making more margin, buying the drug cheaper and getting a larger spread. 6 of the top 20 services or treatments have some connection to behavioral health, the most in the index’s 11-year history. New index here for full analysis.
4. Marriage Is What Brings Us Together, Today: The effort by some PT companies to affiliate or merge with hospitals makes sense given the trend in bundled payment and episodic payments for orthopedic surgery, but there may be a better partner others will consider as a less conventional, but healthier marriage: the worker’s comp insurer. A number of worker’s comp companies—big and small--tell us they are strategizing around acquiring interventional pain and physical therapy providers, as well as a tele-psych service, and identifying exclusive substance abuse treatment partners to gain control of costs and outcomes. In one review, the work comp company said 41 of 100 cases had overuse of both PT and IPM and ‘missed underlying psych’ issues, including PTSD and drug addiction. The strategy is more so in white-board concept stage than formal discussions but is a signal of the growing demand for integration between payer and provider.
5. Live Case Manager, But Not For ABA: Like waiting for your turn to put waffles in the slow-moving toaster when you needed to be on the road to school and work 10 minutes ago, there’s a certain measure of frustration that comes from being in line. Few insurers have figured out the secrets to faster response to managing care but Aetna is trying, by changing its precertification process into a fully queue-based system with a live care manager handling precertification when a patient or provider calls in. ABA services are not evaluated ‘live’, at least not as of yet, in part due to the emerging nature of the service and sheer volume.
6. App Over Entree: A new app that can help someone suffering from depression or anxiety to avoid self-harm could be a new opportunity in the battle to manage care and rising costs in behavioral health. The ‘Calm Harm’ app, unlike ‘self-assessment’ tools that insurers use to give people a chance to better diagnose themselves before accessing the health system, provides strategies to help a person get past the moment of wanting to self-harm. A few mental health providers are using it as part of discharge planning, what one medical director for a Medicaid plan in Pennsylvania called ‘the kind of value we need more of.’ Whether these apps and assessments bend the cost curve is another story: In a conversation I had with an Aetna manager in between basketball games last week, he said these apps have a bigger impact than you’d think: ‘Still figuring out how to measure impact,’ he said, ‘but we think about 5, maybe 10% of population who use these more than once end up solving their challenges without a medical visit or prescription. Click here for more on the Calm Harm app.
7. Midwife Win & Loss: A Wisconsin state law changed in 2018 to allow licensed midwives to enroll as ‘providers’ for the state’s Medicaid programs but Anthem has decided for now not to contract with these type of providers, so they won’t cover services midwives perform. The plan will cover nurse practitioner services if the NP is certified with the nurse midwife specialty.
8. Scope of Practice: A reminder that beginning in March Anthem will implement a new policy regarding reimbursement for services or procedures performed outside the scope of a provider’s license. If a provider performs a service or procedure that is outside of the provider’s scope of license, reimbursement may be denied. Details next year on the situations that may impact your practice.
9. Lady Gaga Contracting: Home care companies seeking better managed care contracts ought to send their aides to Gaga concerts for mental health CPR. ‘We just gave a better contract to a home care company because it was the only one in our region whose aides had gone through the training,” says Mary Phelps, a case manager with BCBS in Kansas. The number one goal of the Gaga-led program is suicide prevention. One of our reporters took the training in November – click here for the report.
10. Extra Point: My freshman son went through a bit of big man on campus moment in December, averaging 18 points for his hoops team. He went cold earlier this week, 3 for 15, and found himself sitting more than usual in a loss to a rival. My dad, wife, and just about everyone else felt bad. Jack was down – depressed, over a game. Not sure why, though: being the next Larry Bird or, sorry for the old man reference, Steph Curry, is not the goal here right, nor is it baked in reality. Nor is perfection. He was addicted to the swish, the minutes, the teammates jumping up after a go-ahead 3, but like a lot of addiction, he fell down. He is human. On Thursday, he finally gave me his perspective on the game and he asked for my advice. ‘I don’t have any,’ I said (of course I was a legend in small town, winning all our family games of horse, so I could understand why he came to me). ‘No advise kido. I think what happened in your game was perfect.’ Jack looked at me like I was ET. ‘Wait, what?’ I paused and chuckled, ‘Yeah, perfect. You probably won’t understand it for awhile, maybe not ‘til you’re in your 40s, but someday’