1. 26: Percent of plan premium dollars, according to a poll of 19 regional insurers, that goes to physician services, 25% to inpatient, 21% to outpatient facility care, and 10% to Rx, but pharmacy varies by plan and over the last few years has definitely taken a larger chunk of the total premium dollar, driven by specialty pharmacy cost. Today, the annual trend in specialty pharmacy net of rebates is 15-20% (e.g. the PMPM on total drug costs), say some sources, compared to the 9-11% it was a few years ago, whereas whereas for traditional (non-specialty drugs) the trend is in some cases negative. Medicaid has highest trend due to lower generic options and its covered population which see higher prevalence of asthma, ADHD, mental health, and substance abuse, conditions where drugs are less often generic.
2. Three if by Air: A southeastern Blue plan is getting tougher on air transports instituting a max pricing policy that gives contracted providers a rate 5x Medicare rates and others out of the network 3x Medicare—both substantially lower than the typical charges, which in recent years have been around 10x Medicare. In 2016, more than 2,000 BlueCross members received air transport as part of their care in Tennessee. ‘We paid more than $50 million for those services, which reflects a 73% increase from just three years ago (29m),’ a source for BCBS of Tennessee reports. About half of payments were for non-emergent situations, one in which the plan paid more than 450k for a fixed wing transport for a patient coming from Arizona back home and $25k for a patient being transferred between hospitals just 2 miles apart. Details on the results of the plan’s strategy to increase rotary and fixed wing contracts will be discussed in an interview in a couple weeks.
3. Working For The Weekend: United Healthcare just dipped into the 1980s for a new policy that it hopes will help doctors add hours. The MCO is going to be increasing PCP reimbursement for evaluating and treating patients on weekends and after hours, which may help those of you in this area either extend hours, add staff, or compete with urgent care. We shall see if this works. If the PCP provides what UHC calls ‘acute care services’ after hours or weekends, they can bill a code called 99051. Policy takes effect August 18th.
4. NeuroMonitoring: A new policy from United Healthcare takes effect in September. It will deny neuromonitoring if performed outside of the hospital, like a surgery center. Separate reimbursement will only be considered if done by someone other than the surgeon or anesthesiologist.
5. TeleMed Takes Direction: New Directions, the specialty benefit manager, has entered into a national arrangement with a tele-mental health company, TalkSpace, that allows 24/7 access to a licensed therapist via an app. For owners of brick and mortar mental health practices in places like Minnesota where New Directions manages behavioral health for insurers, the partnership should impact utilization. Our earlier story on this by clicking here .
6. Vape Nation: 28% of 12th graders surveyed said they have ‘vaped’ in the past year nationally, one study revealed, while our own poll suggested higher numbers in more affluent communities. The trend of smoking E-cigarettes is on the rise with even younger people and researchers are afraid that it will normalize smoking regular cigarettes again. Even more concerning, young people are ‘vaping’ with illicit drugs. Full story here
7. Extra Point: My high schooler took one of those single-credit summer classes last week, a health class where the kids watched endless streams of videos about stress and marijuana, both gateways if you will to a host of medical problems in life. The latter, marijuana, is interesting given what’s happening in some states with medical marijuana dispensaries. Legalization is creating a host of challenges for worker’s comp insurers according to my neighbor who manages work comp cases, given the amount of time marijuana stays in the system and prescribing challenges for pain management doctors who are used to knowing the exact dose when prescribing pills, but are now entering an unknown. Jack got a solid 97 on his final exam. Like any good dad, I said, ‘What tripped you up?’ He said there was one of those questions where the teacher asked students to pick the one option from a list that wasn’t an STD. ‘I thought pumonia sounded like an STD, right?, he said laughing’ I suppose you’re right Jack, but the word on his paper was pneumonia! ‘I’m not sure what’s more concerning kiddo, that you got an A in a class watching videos or that you couldn’t pronounce pneumonia, the grandfather of diseases!’