61: Percent of college kids polled by my 17-year-old this past month via his 2,300 Instagram followers who were sick enough in the last 30 days to miss class, take Nyquil, call home, and contemplate whether to go to the clinic given the risk, in their mind, of being quarantined or sent back home. Just 10% who were sick went to the clinic. My son Jack was not one of them, but the upside is he called home…
New Uterine Fibroid Treatment Covered: Anthem will begin covering an intrauterine ultrasound system offering treatment for symptomatic uterine fibroids that does not require an incision or surgical removal of tissue, and is an alternative to hysterectomy and myomectomy. Wait times for less invasive treatment options for uterine fibroids can be up to 3 years, so Anthem and eventually other payers added coverage for the Sonata technology to provide expanded access to a non-surgical option for women.
Doing A 180: Premera Blue Cross is extending its length of approval for all prior authorizations (PA) from 90 days to 180 days, retroactive to any PAs submitted on or after August 16th. The health plan also expanded its coverage for HIV pre-exposure prophylaxis (PrEP), effective September 17th, and announced they will follow Medicare’s upcoming change to physical therapy assistant reimbursement, which means starting January 2022, PTAs will be reimbursed at 85% of the contracted fee schedule rate.
CloseKnit Model: CareFirst in Maryland is the latest health plan to embrace the virtual health trend, having recently launched a new virtual primary care practice, CloseKnit. CareFirst's innovation and investment arm, Healthworx, designed the CloseKnit app and model, which lets members see most physicians virtually for preventive, primary, urgent, and behavioral care, and get in-person care referrals when needed. All CareFirst commercial members are eligible to join CloseKnit, with costs paid through members’ insurance benefits. According to our weekly poll, 23% of payers believe primary care will be the specialty most used via telehealth even as the risk of COVID decreases, followed by behavioral health. Specialties including more hands-on care by the physician, such as cardiology and orthopedics, are not expected to see much use of telehealth post-COVID.
Concussion Test Falls Short: A doctor once asked Uncle Richard a series of questions after his apparent concussion: “Do you know where you are?” “I’m at Mercy Hospital.” “What city are you in?” “Springfield.” “Do you know who I am?” “Dr. Jones.” Uncle Rich then turned to the nurse and said, “I hope he doesn’t ask me any more questions.” “Why?” she asked. “Because all of those answers were on his badge.” Concussions are not all that funny, although that moment was. Diagnosing them used to be difficult but cognitive testing has improved amid rising prevalence. Some insurers have been monitoring the cost to diagnose given significant increase in concussions and the cost to treat. This fall, Amerigroup decided it will not cover an eye movement analysis that uses non-spatial calibration. It’s not medically necessary in this case.
Digital Duo: Northwell Health and Walgreens are launching a five-year partnership that aims to expand and improve retail health services by developing new digital offerings and pharmacy services. Northwell Health telehealth providers will serve customers using the Walgreens Find Care digital platform across New York state and all Northwell Health employees can use Walgreens as an in-network pharmacy.
Caregiver Pursuit: 24 Hour Home Care of Los Angeles has acquired GrandCare Health Services “caregiving” division in an effort to further expand its homecare services across Southern California. GrandCare will focus on its main services, providing in-home orthopedic therapy after knee, hip, and spine surgeries. Look for both payers and providers to pursue more of these models.
In Network, Redefined: Diagnostic tests completed at a facility that isn't a "designated diagnostic provider" are no longer covered for United Healthcare’s small group commercial members starting in 2022. The policy took effect for large group plans in July although we will see how the policy plays out. Labs that are designated will be reimbursed at a fixed rate. Coverage apparently will be denied for patients who receive testing at a non-designated lab—even if the provider is considered "in-network." UnitedHealthcare is providing members a one-time exemption if they use a non-designated lab – sort of like other insurers have done when allowing patients to use any pharmacy for the first fill – but otherwise, members will need to pay out of pocket. The requirement doesn't include inpatient or emergency room tests. The policy is focused on targeting the gap between hospital outpatient lab costs vs. freestanding.
Extra Point: David is an iconic name in my house – there’s my middle school soccer team that after 23 straight losses finally won a game last night against Goliath. A 4 foot 5 seventh grader who identifies as non-binary, and lives in a neighborhood where kids can’t play outside or they may get shot, made the winning assist. David is also my older cousin who is a scientist at Sloan Kettering but in my world may just always be the guy who stole a few dozen Yoo Hoos for us from Popeye’s fridge back in the early 70s. Without knowing it, he taught me how to be confident and be who you are, taught me a bit about what it means to grow up gay at a time when many made fun of it and few talked about it. He taught me how to not just tolerate, but to embrace. David is the character our teenage daughter loves most on Schitt’s Creek, perhaps in one way because he struggles with identity but finds a way to be himself and make her laugh so much the Yoo Hoo went up her nose the other day. Healthcare is looking for more David’s these days to fight against behaviors and thinking that seem to be stuck in the ‘70s. A reversal this week of a policy that denied fertility services to an LGBTQ individual is a David if I’ve ever heard one – and while it may not be the last battle for equality in healthcare, it’s a sign perhaps that we are moving away from just tolerating each other. In this piece, we explore the physical and mental health challenges confronting LGBTQ teens today.