1) 2040: The year when Alzheimer’s disease will consume about 25% of the Medicare budget, according to a new study, aided in part by addiction to smart phones that can cause plaque buildup in the brain, the same plaque linked to Alzheimer’s. Brain scan of people in their 20s showed high levels of buildup due to excessive iphone use. The findings and outlook have implications for policymakers as well as families and employers given the massive direct and indirect cost of the disease. Read neurologist reaction by clicking here
2) Genetic Test Plus: Testing for Cadasil, a hereditary stroke disorder, no longer will require providers to try other tests first under a new Regence BCBS policy. This payer is so active in monitoring guidelines and updating its genetic testing criteria that other health insurers we’ve talked said they ‘look at their policies’ and ‘have adapted them in some cases’
3) MA Home Care Disrupter: A number of Medicare Advantage plans recently announced a decision to delegate oversight of home health services to myNEXUS, a benefit manager. Blue Georgia’s MA population is one example. It’s interesting that the benefit manager describes itself as ‘a disrupter’ of post acute services, just in case there were questions. PCPs (and hospitals) in states where this company is now overseeing home care coordination need to go through them, and not the plan – anticipate ‘steering’ as well as more hoops to get approvals.
4) Extra Payment For Surgeons, Maybe: Sort of like parents holding out the allowance until they inspect under the bed, Florida Blue is now going to start to give the proverbial extra credit with an enhanced payment to surgical providers if they can prove their procedures take a lot more work to complete successfully, like an unusually lengthy procedure, excessive blood loss complications during a procedure, trauma extensive enough to complicate the work and that which can’t be billed separately, and other so-called ‘pathologies’ that interfere with the surgeons ability to do the procedure, like a tumor or genetic malformation. A modifier (#22) would need to be billed with the correct code and the plan says they’d request documentation, images, and other evidence before agreeing to pay.
5) Home Infusion Policy: An updated policy for home infusion will reduce the per diem reimbursement when multiple codes in the same therapeutic category are used, so reimbursement will fall if multiple codes are used for antibiotics/antifungals/antivirals, chemotherapy, and pain management. The highest valued procedure will be fully reimbursed, but the second procedure will only get 50%. Each procedure after that only gets 25%. The reason for this is that the per diem includes things like “all necessary supplies for delivery of drugs,” which, if you have for the first infusion, you won’t need for the second infusion. This is an attempt to reduce double/overpayment for things that are being duplicated. TPN, Enteral nutrition and hydration are not impacted by this policy since only 1 per diem code is allowed per day. Details here
6) Pharmacy Ramblings: We sat down with a few clinical pharmacy directors recently and 3 of the 4 said the shift to outcomes-based contracting for drugs is a great idea, but is facing roadblocks as payers and pharma companies can’t get to agree on the measures of success and, when they do, there’s considerable argument over the savings split. For now, their attention remains squarely on specialty drugs. The annual trend net of rebates in pharmacy costs is about 15-20% on specialty (e.g. the PMPM on total drug costs), whereas for traditional (non-specialty drugs) the trend is in some cases negative. The annual specialty trend a few years ago, like 2012, was probably around 9-11% net of rebate. A lot of the drug cost is ‘rebatable’ and the size of rebates has escalated. Rebates used to be 8-15% but that’s changed dramatically with Eli Lilly, for example, just paying out 40%+ for Invokana to treat diabetes. There are therapeutic classes for which you get high rebates and some you don’t (HIV might be one area for example, although with generic Atripla that may change). Medicaid, in some cases, has highest drug cost trend due to lower generic options and the population, which includes a higher prevalence of asthma, ADHD, mental health and substance abuse), conditions where drugs are less often generic. Comparably, the Medicare bucket has a 89-92% generic fill rate. Health plans benefit from ongoing rebates for chronic care treatments, like for Remicade; 92% in a poll we did require Remicade first, but as time goes on pharmacy directors anticipate that Biosimilars will become ‘more price sensitive’ and impact the overall trend. Inflectra, the biosimilar for Remicade was 10% less in the fourth quarter of 2017, helping payers, but of course hurting providers who relied on the markup although a biosimilar approved under the BPCIA pathway is reimbursed at ASP plus 6%,
7) No Pain, No Gain: A new health plan policy in the peach state may impact current and former Georgia Bulldog football players, not to mention anyone needing pain management. A trainer for the school said ‘injections’ have been a way to get ‘certain players’ ready to play, without resorting to medication. But in July, the state’s top payer, BCBS, will begin to more aggressively monitor pain management, restricting aspects of interventional procedures, but loosening others, all through a new arrangement with AIM, the benefit manager. There will be more limits to the number of diagnostic medial branch blocks allowed both before and in between injections. In contrast, if you’re giving a patient an epidural injection for post-op pain there is no longer a pre-approval requirement, under certain diagnoses.
8) Woman’s Health Pre Pay Reviews: There’s been more interest in obstetric, pediatric and hospital woman’s health services lately, which 43% of 311 hospital c-suite leaders in our poll last week said was emerging a top service line priority. The interest is largely coming from board strategy planning sessions on how to remake the hospital of the future. ‘There’s pressure on all aspects of our business – but woman’s health services is perhaps one we can leverage, and allow us to own the care from pre-birth, to birth then into all aspects of the child’s care’. Payers, for their part, seem to noticing and creating a host of new policies around newborn care, many very routine, but nonetheless a sign they want to make sure payment is appropriate. Blue Georgia in September will start a new facility payment policy around more complex newborn admissions, such as those where the child is in the NICU. Pre-pay evaluations will take place. If documentation is missing and if the hospital never got pre-approval, the payment will resort to a normal delivery level amount.
9) Diabetes Monitoring: Harvard Pilgrim is updating their commercial continuous glucose monitoring system medical review criteria including a name change to diabetes management devices, extensive criteria revisions as well as changes to prior authorization and coverage requirements. Among other criteria required for replacement, the clinician overseeing the member’s diabetic condition must submit documentation in the form of clinical notes or letters supporting the necessity of the device’s replacement and continued use. More specifically, the policy and coverage criteria addresses rules for monitoring, interpreting, physician supervision and multi-day use.
10) Extra Point: So I’m playing mister mom this week following my wife’s bad luck surgery to repair an ankle she shattered walking the dog with flip flops, a dog I wanted. I’m playing part home care aid, therapist, short-order cook, DME advisor, pharmacist and meals on wheels coordinator. Still waiting for my bundled payment for this. The good news is there’s a lot of evidence of good quality care. On Wednesday afternoon when the nerve block was finally wearing off, I managed in a 10-minute span to get Janine her Advil, do a conference call for work, start a laundry load, and make the kidoes supper. Only problem was the supper – ‘dad, why is my milk blue?’ I suppose pouring the Tide into the cereal bowl was my bad, but good news is the laundry has a nice milky scent.