12: Percent of hospitals receiving incentive payments for reducing cesarean sections and meeting quality goals related to episiotomies, early elective deliveries, and maternity care under a pilot from Tricare set to conclude in March 2021. Tricare, which provides healthcare coverage to 9.6 million uniformed service members, retirees, and their families, has several value-based initiatives underway. 3,640 hospitals participated in the maternity pilot.
Asthma Device: Anthem is pairing with UC-Irvine to study whether smart devices can help asthmatics predict an asthma attack. Anthem members will be part of the study. Smartphone-based technology is now being used to treat a variety of conditions. Results could be used as part of clinical and payment redesign. For example, an allergy practice in east Texas is getting an incentive payment these days from a Medicaid plan for giving its highest-risk asthma patients portable spirometers that transmit results back to the physician, help the practice monitor pulmonary function, head off deterioration, and with any luck, see progress.
Pharma Outcomes Pay Model: Highmark, which is now expanding its membership in the Northeast, has entered into an outcomes-based agreement with drug manufacturer AstraZeneca for Fasenra, a maintenance treatment for patients with severe asthma that around 500 Highmark members currently take. The agreement will apply to both commercial and Medicare members and is the second agreement between the health plan and manufacturer. They previously signed a similar deal for asthma and COPD treatment, Symbicort, and last year, announced that they had demonstrated positive results in improving health outcomes.
Rebrand: On the surface, Cigna’s rebranding of its health services division this fall as Evernorth may seem more marketing than healthcare, but if you pull back the curtain, the services under the new brand indicate how the company is going to try to manage care, shape networks, and redesign payment. Evernorth will include PBM Express Scripts, specialty pharmacy Accredo, and medical benefit manager eviCore along with other existing and new products like Healthy Ways to Work, a return-to-work program for health plans and employers, the fertility program FamilyPath, a gene therapy program called Embarc, and mental health platform inMynd. These connected companies will be able to share medical, pharmacy, and psychosocial data and offer a more comprehensive benefit than we have seen from insurers.
Addiction Outcomes: Anthem announced they more than doubled the number of members who are receiving whole-person treatment for opioid use disorder across Medicaid, individual, and employer plans. Four years ago, Anthem pledged to increase the number of members receiving both drug therapy and counseling treatment and the numbers show they attained their goal. The combined percentage of consumers across plans with opioid use disorder receiving both therapies went from 22% to 56%. Medicaid plans alone increased from 24% to 65%. On our behavioral health roundtable earlier this week, two companies--Aware Recovery and Eleanor Health--shared case studies about their value-based PMPM models that center around whole-person care.
Health System Maneuvering: Two Blues plans are partnering with providers to offer additional health plan options next year. Horizon BCBS in New Jersey is launching a new Medicare Advantage plan, Braven Health, through a partnership with Hackensack Meridian Health and RWJBarnabas Health. Braven Health is the first payer-provider owned health plan in the state, and will be available starting next month, going into effect at the start of 2021. In Wisconsin, Anthem and Ascension Wisconsin are teaming up to offer ACA health plans in five Wisconsin counties in 2021. The Anthem plans will feature Ascension Wisconsin’s 24 hospital campuses, 110 care locations, and more than 1,300 physicians, including Children’s Wisconsin for pediatric care.
Diagnostic Cost Variation: A new study published in the Journal of General Internal Medicine shows that COVID-19 diagnostic tests range from a penny to more than $14K. The study reviewed a sample of 182,149 diagnostic testing claims from 764 providers in 46 states and the District of Columbia. All claims were submitted between March 19 and July 19. Independent labs were the most common facility type for diagnostic tests and also had the highest prices.
The Purple Kit: CVS Health is sending all Medicare members “Caring for You” kits in preparation for flu season and the pandemic that include over-the-counter items to help members stay healthy. The purple boxes will include a thermometer, hand sanitizer, and two Aetna-branded facemasks, as well as other items. This will be a one-time benefit and will affect members who enrolled before August 1, 2020.
Vision Meets Dental: MetLife plans to acquire Versant Health, which owns Davis Vision and Superior Vision, by the end of the year. Through the deal, MetLife, a national dental insurer, will gain access to Versant Health’s 35 million members, and MetLife’s existing customers will gain access to Versant Health’s extensive provider network, which is one of the largest in the vision industry.
Think About It: A bookstore is one of the only pieces of evidence we have that people are still thinking. This is Jerry Seinfeld’s opinion, not mine, but it makes sense and when you’re looking at whether a healthcare business has a population that could potentially hurt your ability to effectively take risk, just think about all the evidence you can find stored in your data, or the plan’s data. Look for the number of address changes in the prior year, or gaps in insurance enrollment, or if you can tell whether the patient was “auto-assigned” to the primary care practice or “self-selected”. These psychosocial data points can be “high predictors of non-adherence and bad outcomes,” says Barry Lachman, MD, who’s heading up a community development program in Dallas to address the effects of poor housing and food insecurity on asthma incidence and overall health. And if the data is aggregated effectively, it can help practices help their health plan partners figure out who will fail, before they fail.
Extra Point: If I were to tell you one of these were true and two were false, what would be your choice? (a) A $90 fee is provided to this dermatology group by a commercial payer for diagnosing depression in teens with serious skin conditions, including significant acne, while another group hired a pair of psychologists to help counsel teens with significant skin issues. The health plan is contemplating an enhanced reimbursement rate for both groups as part of a 2021 initiative to support investment in specialty practices doing value-based care. (b) A Medicaid plan is now near the end of its first year paying a skilled nursing facility an additional $230 per diem for helping manage and treat substance use disorders in its residents, and an additional 50% share of savings for lowering hospital admissions below a baseline target, based on the facility’s prior admission rates. The nursing facility hired a team of SNFists to help provide coverage, particularly on weekends that accounted for 75% of admissions in 2019, and as a way to limit what the plan calls ‘avoidable admits’, like for a patient with a 101 fever. (c) An MA plan sets a target bundled rate of $13,900 for hip arthroscopy, inclusive of two months of post-op physical therapy and pain management, and after a year, the average total cost for the episode was $11,500. Under agreements, orthopedic surgery groups are the accountable providers and get a 35% share of savings below the target but with total costs below the benchmark, the plan decides to lower it to $12,000 and change the share of savings to 50-50. Which of these is true? Email your guess to be entered into drawing for a complimentary gift card. Answer next week.