66: On a hunch, about two thirds of parents of children on the spectrum are, themselves, somewhere on the spectrum too, though the vast majority self reported that they were never formally diagnosed, according to a random exploration into ABA and autism diagnostic and treatment spending by Paula Ortiz, a recent college graduate who conducted the study for her Master’s degree in Rhode Island. Ortiz acknowledges this was just a random sampling of 100 and may not mean anything. She works two jobs to help pay for her degree, and raises a 6-year-old with significant verbal delays, and “so I obviously figured there was a connection”. She says she was diagnosed with the neurological condition Apraxia at age 11 – Apraxia can greatly limit a person’s ability to speak but it is treatable, as it was for Ortiz.
Payback For A Less Than Good Outcome: Lung cancer patients who fail to get to goal on Alunbrig will be part of a new risk-sharing arrangement between Takeda and New England insurer Point32Health, formerly Harvard Pilgrim and Tufts. Takeda has agreed to reimburse the insurer should the treatment not work. These arrangements have been tricky to build but there have been some strides. Highmark BCBS started reviewing specific pharmacy and medical criteria back in 2018 to determine if COPD or asthma-related symptoms in patients on the drug Symbicort were in-line with clinical trial results. If Symbicort didn’t perform as expected, AstraZeneca provided a rebate.
Here’s The Skinny: Only 11% of dermatologists in our quick poll say they are taking new patients compared to 59% of dermatology PAs and APRNs, including my own appointment with a PA that, wait for it, will be in January 2022.
Unacceptable: So a long-time friend who’s been a network development director for a national managed care company says he sometimes gets a flurry of requests from care management vendors to manage care at home – 120 in one year – “but I would almost rather see another MCO try it first to see if there’s ROI…and I do worry about how these things impact my local docs and our value based agreements.” In some situations, he doesn’t love how the national team will at times “basically force” the local networks to use a vendor. “We usually are given guidance on what they want the contract to be – what’s acceptable or unacceptable.” Sounds a lot like my Saturday mornings – mowing the lawn and helping fold with the laundry (acceptable), playing a 3 hour basketball game then heading to the pub (unacceptable).
Social Seinfeld: The comedian used to say he liked soup so much because he was a lazy eater. Soup kitchens used to be the old model of helping underserved, a kind of symbol of how those more fortunate could assist poor, homeless, hungry. But the science and data around social services, including the benefits of a single bowl of hot soup, are changing behavior. Now, more insurers as we predicted 6 years ago are hiring social workers and an increasing number are designing social service networks to help improve a person’s physical and mental health. A Michigan insurer, Priority Health, was the first to offer financial incentives to providers who screen patients and submit information on social determinants of health. Physician practices recognized as a Patient-Centered Medical Home can use an approved tool to screen patients and complete the SDOH survey to receive increased reimbursement.
Specialty Care’s New Home: Oak Street acquired virtual specialty provider RubiconMD, allowing Oak Street to expand from just primary care into specialty care, something we’ve been suggesting these value-based PCP groups would (or should) likely pivot to. RubiconMD provides access to specialists across 230 specialties. One Medical, another PCP group focused on risk-taking arrangements, launched a new chronic condition management program this month as well, in an effort to also expand beyond primary care.
Kidney Bean There Done That: Blue Shield of California is collaborating with Cricket Health to launch a care coordination program for members with late stage chronic kidney disease (CKD) or end-stage kidney disease (ESRD). This program is part of Blue CA’s Health Reimagined initiative and will measure key clinical measures related to CKD and ESRD, including ability to reduce hospitalizations and allowing alternative dialysis sites of service.
Shark Tank PBM: If you have a healthcare business idea, maybe take it to the show. I personally want to create a kind of moving belt system that you can jog on without actually going forward, though something tells me that’s already been done. Dallas Mavericks owner and Shark Tank’s most well known “shark” is launching a PBM this month that will sell generic drugs at a transparent fixed rate. Others are following—a national employer group with members like Walmart, Costco and Microsoft is launching EmsanaRx for large employers, arguing that employers often “don’t have access to information about drug costs, discounts and administrative fees”.
Patient Communication Lag: “There is a lot of difficulty with providing access and alerts between two practices so sometimes patients get into a crisis, and an intervention is late in coming.” This from a physician noting challenges with patient and provider communication. Over half in our Poll of the Week believe patient to provider communication could be improved. Respondents pointed out the difficulty of communicating between the patients’ multiple practices, as most practices do not use the same messaging platform.
Pediatrics Relaxing Authorization: eviCore is actually going to relax what it asks for during the authorization process for musculoskeletal and PT/OT interventions to treat kids with neurodevelopmental conditions. They call these specialized therapy requests.
Extra Point: Strange but true marriages continue to find their way onto healthcare’s alter. The latest in Missouri is a merging of Citizens Memorial Hospital, Bolivar OBGYN and, wait for it, Butterfield Park Pediatrics. Sounds like a page out of Prince Humperdink and Buttercup’s odd coupling in the Princess Bride, but actually combining pediatrics and women’s health is likely an emerging trend. Expect more health systems to expand these service lines and for more commercial insurers to redesign payment to favor these double-specialty practices. The amount of ‘episodes of care’ and clinical efficiencies are significant – just think about an encounter involving a child potentially on the autism spectrum, or a new mom not needing to shuffle between OB and pediatrics amidst post-partem. Even stranger is a dental practice out west that’s talking with an allergy and asthma clinic about merging forces to help the Medicaid population. Patients taking asthma medication are often at risk of tooth erosion or periodontal disease. The marriage bug likely makes its way into home health too – will an Instacart join with a home care agency, will a physical therapy clinic merge with an outpatient psych therapy practice. My own marriage had its own strange start if you talk to my in-laws – a short Italian marrying a tall Irish Catholic. A Yankee wedding a Red Sox. But our marriage probably has thrived on the differences. After 21 years in sickness and health, it’s still working. My dad used to say you ought to be able re-contract every 5 years. I guess I could ask for a fee for service allowance or incentives every time I bring Bridget water or a greater share of the apple pie for risking my life on the ladder, but there a zillion more things she does. This is all to say that some partnerships may seem odd, but that’s just the surface.