1. 350 Million: The total dollars that five drugs cost Texas managed care plans in the fourth quarter of last year. Abilify (antipsychotic) Vyvanse (stimulant) Nexium (GI), Invega (antipsychotic) and Norditropin (growth hormone) were the five most expensive drugs here. In contrast, through the smaller fee for service program, Ibrance, an antineoplastic systemic enzyme inhibitor, was the most expensive drug at just $2 million, followed by Abilify and three stimulants. In terms of utilization, ibuprofen, amoxicillin (the penicillin) and the bronchial agent Albuterol used to treat Asthma were the most prescribed with 2 to 3 x more encounters than the high cost drugs.
2. On Second Opinion: My youngsters used to go to their grandparents if they didn’t like my answer to ‘can I have $3 for the ice-cream truck,’ a second opinion that would almost always get them a strawberry éclair…hopefully Anthem’s second opinion program has better success than my flawed parenting model. The insurer’s new program gives employees a virtual second opinion from an insurer-selected physician, a program that we think could be a real boost to certain practices who position themselves as quasi centers of excellence in getting the right diagnosis, particularly for hard to evaluate conditions. The insurer says they’ll actually reach out to a certain group of patients who may benefit for this sort of service, such as high utilizers of imaging or surgical procedures. The virtual second opinion service is coordinated by Anthem, who will select the physicians to do the consults. Services available include nervous system diagnoses like MS and Parkinson’s, advanced hip and knee degenerative disease, commonly misdiagnosed conditions like Lupus, Lyme and rheumatoid arthritis, and digestive conditions like Crohn’s. Physician groups ‘selected’ as the preferred second opinion vendors stand to gain new patients and better positioning within Anthem. Reach out for a full list.
3. Molecular Testing Check: Starting in July, pre approval will be required by United Healthcare for several genetic and molecular tests in the outpatient setting. Link to the codes/tests here
4. Michigan 100: Primary care doctors in Michigan will be paid $100 a pop by the Blue plan networkl for closing gaps in Medicare Advantage patient diagnoses, such as ‘confirming’ a diagnosis or based on a face-to-face visit determining that the patient no longer has the condition previously reported.
5. Home Pharmacy Limit: Optum, as of this summer, will limit opioid prescriptions via its home delivery pharmacy service to 30 day supplies. The policy only applies to commercial patients. Cigna, for its part, is equally aggressive. It does quarterly ‘reassessments’ of the benefits of opioid therapy and starting in July requires pre-approval for patients prescribed a total daily dose of 120+ MME.
6. Partners: Harvard Pilgrim Health Care is exploring a collaboration with Partners HealthCare that could take the form of a financial integration or other arrangement. Harvard Pilgrim already has partnerships with area hospital systems via its Benevera Health value-based care entity.
7. Vape Movement Sequel: We reported last week that 891 of 1,216 high school students said they know of someone who has vaped or have themselves tried to vape in the last year. The consumer poll was shared with a guidance counselor at one of the schools who was at first ‘floored by the numbers’ but after investigating has set up a Vape Debate, asking students to debate on stage the pros and cons ‘without punishment’. ‘We want to open this up rather than it be a secretive thing – we’re talking about kids’ health and behaviors, but it goes much deeper and I don’t think we should just dismiss those who’ve tried this and suspend them. Clearly, this is a problem that may benefit from managing out in the open,’ says Sharlene Forlough, who is a counselor at a large high school in New England. We will cover the debate and report back. Students polled said the vaping ‘is everywhere – in the locker-room, parking lot, bathrooms, and quietly in the woods after dusk.’ Of the 320 students who’ve tried it at least once (so about 25%), 196 said their mom or dad works in the healthcare field and, except for only a few dozen, they ‘have no idea’ what I’m doing. This poll is conducted anonymously with student athletes in New England.
8. Hackers Meet Doctors: In case you missed it, last week’s report from a meeting of physicians and software developers highlights the emerging trends in healthcare technology. Highlights here
9. Extra Point: A 78-year-old was back in the hospital this Wednesday to have an additional drain installed but her husband, a man who taught my youngest kids how to fish and took us all on bizarre yet memorable rides to a pretzel factory in Amish country, expects she’ll be home this weekend. The issue is, he is suffering through radiation sickness with acute fatigue and weight loss, so taking care of her is impossible. Their son, 43, has traveled cross-country to help this week; his wife and their kids will muddle through and he will miss work to help his parents. Step one is to set up hospice. The older couple is ‘trying to stay at home for as long as possible,’ and admits to me that ‘starting hospice sooner’ maybe would have been wise given ‘the 20 some trips to the ER and hospital in the past year’. Wendy Abraham, a utilization analyst in Maryland, was kind enough to point out to me this week that very few people have someone to help navigate all of this for them, and that there’s certainly a growing, unmet need for this sort of help. ‘Our healthcare system often forgets about the human nature of our elders and puts more stress on them rather than trying to decrease it.’ I personally haven’t counted the costs for all these ER trips yet but they are staggering, all paid for through TriCare. We may take the trip down later today, pulling our kids from all their weekend sports and music and social commitments, to lend a hand and perhaps say our goodbyes to this couple. This to me is the root of managed care: trying to do the right thing sooner than later, and trying to make the right decision even when it’s hard.