3D: Beginning in April, Harvard Pilgrim Health Care will provide reimbursement for digital breast tomosynthesis (3D mammography) for commercial members in all states the plan covers. Harvard Pilgrim recently merged with Tufts Health Plan, although the two will keep their products separate for the time being.
Lab Disruption: United is planning to launch a Designated Diagnostic Provider program in July 2021 and there is already pushback against the health insurer’s plan. The program is designed for commercial members and will only cover outpatient lab services when delivered by freestanding or hospital lab providers that meet certain quality and efficiency requirements. The American Medical Association says that this could mean members may have difficulty finding qualifying labs and could lead to more surprise bills. United’s new policy says that, “Non-Designated Diagnostic Providers will remain in-network with UnitedHealthcare, but outpatient diagnostic lab services will be denied as non-covered for members with Designated Diagnostic Provider benefit designs and your patients may be liable for charges.”
Skin In The Game: Skin cancer diagnostics company, DermTech, entered an agreement with BCBS of Texas to make its Pigmented Lesion Assay available to about 6 million members. This device allows for early detection of melanoma and will be available as an in-network option for BCBSTX’s Blue Essential, Traditional Indemnity, and PPO/POS members. BCBS of Illinois was the first Blue’s plan to make this device available to its members, followed by BCBS of California, and now BCBSTX.
Raising Arizona: Health Choice Arizona, a subsidiary of Blue Cross Blue Shield of Arizona, announced an expansion of its digital health suite by offering Wellth, a digital behavioral health program, with the goal of improving medication adherence for members diagnosed with Severe Mental Illness. Wellth members begin each month with a rewards balance. To keep their rewards, members must complete daily check-ins by taking a photo of their medications before they take them via the Wellth platform. Failure to comply with medications is one of the costliest problems in healthcare, leading to diminished health outcomes and increased care utilization, which end up costing the health plan more.
Social Service Partnership: Empire BlueCross BlueShield and Montefiore Health System announced a multi-year agreement focused on improving access to quality healthcare for people throughout NYC, Westchester, and the Hudson Valley. The agreement will include new community outreach initiatives including health events, a partnership to support nutrition services for at-risk populations, and a mobile health unit to deliver essential testing and screening focused on improving community health. This demonstrates the evolving role of health plans and systems in providing investments to address social risk. More on this topic in the coming weeks when we release our social determinants of health national research study.
Rx Cover Switch: Blue Cross NC is implementing a new process when submitting requests for drugs under the medical benefit. Effective April 28, 2021, the insurer will shift its medical drug authorization process to CoverMyMeds and the pharmacy call center team. This change aims to improve turnaround times when submitting prior authorizations for medical drugs as well as allowing a more streamlined experience and user-friendly process for providers.
Kidney Bean: Another health plan is focusing on kidney care for its members, this time through an investment in the company Monogram Health. We recently reported that Humana was partnering with the company to provide kidney disease care coordination services in several states and now SCAN Group, whose holdings include SCAN Health Plan, one of the nation’s largest not-for-profit Medicare Advantage plans, has invested in Monogram. This is SCAN’s first outside investment and likely is not the last health plan investment we’ll see in kidney care.
COVID Effect On Surgery Policy: Despite an overall trend in shifting care from hospitals into ASCs, Molina of Illinois temporarily suspended a new prior authorization requirement for surgical procedures in hospitals, due to COVID-19. The new policy was effective January 2021, but Molina put a moratorium on the PA requirement until 2022.
Opt In For Ortho: Orthopedic specialists have until March 1 to sign up to participate in the TurningPoint Safety and Quality Award Program, in collaboration with Horizon BCBSNJ. This reward-based program will provide incentives for providers when their patients experience fewer complications, infections, hospital readmissions and ER visits following their surgical procedures, as well as reduced out-of-pocket costs for patients. Program begins in April.
Extra Point: Unless you’re Notre Dame football, staying independent is problematic in college sports and a bit of a lesson for healthcare innovators. In its heyday, UConn could have joined the ACC or Big 10 but missed its chance and was left without a football conference and its top tier hoop team was relegated to a lower tier conference. Healthcare providers are in a similar pickle – align with a multi-state health system for higher reimbursement and referrals or hang a shingle independently. Many have tried, including many novel start-ups trying to tackle the cost of diabetes, depression and aging with remote monitoring capitation models only to see the big health system march in with their own solution. As you evaluate home based solutions, consider the risk of independence or waiting for the perfect partner, as UConn did. Ultimately, unless you have the ethic of Rudy and a brand like the Irish, be careful - the insurer may like the little independent, but it needs the big health system.