60: Humana is purchasing the remaining 60% interest of Kindred at Home and will rebrand the company through Humana’s new healthcare services brand, CenterWell, going by CenterWell Home Health. Fully integrating home health allows Humana to accelerate their value-based operating model at scale, more closely focusing on improving patient outcomes and reducing the total cost of care. The payer plans to divest their majority stake in Kindred’s hospice and community care operations.
Home Care Oversight: BCBS Michigan is contracting with CareCentrix to manage home health care services for MA members, effective June 1, 2021. CareCentrix will be managing all prior authorizations and recertifications for home health care services, including PT, OT, and ST.
Before We Pay: Somewhat like reviewing the bill at the Denny’s diner to make sure you are not on the hook for the side of pancakes you never actually got, several payers including Anthem are now using analytics to target physician practices who are billing higher levels of evaluation and management codes. The goal is to inspect patterns and potential upcoding. Anthem will review claims prior to payment and, in a likely case, adjust reimbursement to a lower level, though in some cases may just ask for more documentation.
Actually It’s Not What You Thought: Despite reports of big jumps in anxiety medication scripts, alcohol treatment admits, crisis center waitlists and suicide attempts, actual mental health diagnosis was down among children and older adults in 2020 vs. the prior year, mainly due to fewer in-person interactions like school and church that lead to earlier intervention and diagnoses for depression, anxiety or dementia, according to new findings from the Anthem State of the Nation's Mental Health Report. Anthem found a -10% overall decline in mental health diagnosis among children and a -13% overall drop for adolescents diagnosed with ADHD. Experts theorize this is because children involved with distance learning have had less face time with teachers and counselors, which often plays a role in diagnosis. This has been the issue for a 13-year-old 7th grader in Hartford whose isolation has led to more than 9 suicide attempts. The positive is re-entry to in-person school has allowed teachers to monitor and form a plan and, more importantly, diagnose and treat the issue. Getting the teen involved in a daily sports exercise program has been one part of the effort, but as the girl’s teacher said, “This is going to be a long haul for her.” Nearly three out of four mental health specialists and primary care doctors agree, estimating that mental health repercussions from the virus will last up to three years or longer, the study found.
Removing Authorization: BCBS Texas is removing some prior authorization (PA) requirements through their third-party benefit manager, AIM. As of April 16th, a PA is no longer required for certain sleep medicine DME codes and effective July 1st, PAs will be removed for select codes in advanced imaging, genetic testing, and pain management.
The MCO Giveth And Taketh Away: Just like the Bible passage, the positive news above from Blue Texas comes as Aetna will begin requiring precertification for cataract surgery procedures as of July 1, 2021. Placing cataract surgery on the National Precertification List (NPL) will allow the health plan to review cataract procedures for medical necessity before any member undergoes surgery.
Don’t Miss This Episode: Horizon BCBS in New Jersey recently expanded its Episode of Care program to include a new prospective breast cancer episode. Through a partnership with Astera Cancer Care, the episode will provide coordinated, early-stage breast cancer treatment to members. All healthcare services provided throughout treatment will be part of the episode, including lab work, imaging, surgery and post-surgical care, no matter how long the episode lasts.
Van With Care: It may not be Matt Foley’s famous motivational “van down by the river” that inspired David Spade to stop using drugs on Saturday Night Live in the 90s, but this van will likely save other lives as Anthem California has donated $100,000 to the Fresno Center to help the non-profit purchase an office van to bring case management and therapy visits into neighborhoods. This is just continued evidence that managed care plans will continue to fund non-profits focused on social services.
Extra Point: Being predictable may be boring but it pays the bills if you’re a meteorologist in New England, and increasingly if you work in healthcare. I mean in movies we say we like the unpredictable, but to be honest we watch Apollo 13 over and over like 50 times not because Tom Hanks is a convincing astronaut but because we know the ending before it starts, and we love it. We sing with Icelandic Eurovision duo Will Ferrell and Rachel McAdams every morning before school this week because the music lifts us up and makes us laugh before the day starts. If it’s 7:20am, it’s time to play their Song-Along. It becomes our behavior. In healthcare we wish we could predict every outcome, but we can’t. We want to know that the surgery will take 3 hours, require 1 night in the hospital, no complications, 3 weeks of rehab and have Sally running pain free again by the time the Boston Marathon takes off from Hopkinton. We want to know that 20 visits with the behavioral therapist will cost the same each time, that the therapist will have Sally talking freely and confidently by the time she hangs her raincoat in that nursery school cubby in September. We want a good outcome but are sometimes afraid to pay for it. We are stuck often times in paying for each service and don’t have the systems to pay for a good result. We are afraid to change because it’s unpredictable. We ask our doctors to diagnose our pain, treat it and tell us that it will all be fine, but sometimes we forget this is life – and those tumors are unpredictable and might need more than a miracle drug. I predict that by 2030 there will no longer be a fee for service, not without a guarantee that what you’re buying – a drug, a new knee, a better behavior, a pain free shoulder, a working heart, a clearer eye, a cure and a second chance – will be predictable. I’m as certain as I am that tomorrow’s weather will be mostly sunny. Here’s to hoping.