1. By the Numbers: Of 54 million adults suffering from arthritis, 44 percent have limitations that affect mental health. According to the American Psychological Association, anxiety affects blood pressure and high blood pressure often goes untreated in those with rheumatoid arthritis (RA). Chronic daily pain can change the levels of the brain and nervous system chemicals. This changes thinking, behavior and depression.
2. ADHD: Insurance coverage for ADHD drugs and therapy programs is inconsistent between healthcare providers. Cigna released their prescription drug list changes for attention deficit hyperactivity disorder and said that the medications not covered are Desoxyn and Dexedrine. Instead, only the generic alternative is covered in tablet form.
3. Aetna & Epilepsy: What was previously an excluded Aetna behavioral benefit, Vagus nerve stimulation is now covered. This is a procedure that treats epilepsy when other treatments haven’t worked. It is also a treatment for hard-to-treat depression that hasn’t responded to typical therapies. Federal law requires Aetna to cover mental health and substance abuse services in parity with coverage of medical and surgical services.
4. Anthem Enrollment Changes: Anthem reports that medical enrollment totaled 39.5 million members as of June 30, 2018, a decline of 129,000 members during the quarter. The enrollment decline was driven by a reduced footprint in the Individual ACA-compliant marketplace in addition to membership losses in Medicaid. Medicare enrollment grew by 254 thousand, year-over-year as a result of acquisitions and organic growth. Medical enrollment was down 129,000 lives sequentially, reflecting declines in Medicaid, continued attrition in Individual, and declines in the Local Group business. The decline was partially offset by growth in Medicare enrollment, said an Anthem spokesperson.
5. Shingles: Anthem updated its Affordable Care Act (ACA) preventive care coverage to include Shingrix, the new zoster shingles vaccine based on a new recommendation by the Advisory Committee on Immunization Practices (ACIP). Medicare coverage for the shingles shot is only available if you’re enrolled in a stand-alone Part D drug plan or a Medicare Advantage plan that includes Part D drug coverage.
6. Extra Point: In 1978 I’ll never forget the time dad cut my allowance from $2 a week to a nickel after I cut corners cleaning the bathrooms and that same week he took my sister to the baseball game and mini golf. I sulked for a whole weekend, which isn’t a good look for a kind of quiet kid who wears polyester bellbottoms and only listens to Survivor cassette tapes. In managed care speak, Dad cut my rate and my utilization. We were talking yesterday about how managed care plans often do one of the other, but not both when trying to get control of costs for a service or specialty. They’ve often addressed radiology over the years through utilization controls, now in effect forcing these physicians to think about the medical necessity of the scan before ordering it. They’ve typically done the opposite to lab and DME rates, or payment for out of network services, reducing reimbursement rather than managing the volume. In managing autism, a service with coverage mandates, they’re beginning in some markets to do both – evaluating areas where rate cuts make sense and managing visits more closely. Over time, the best way to avoid both rate and volume pressure likely lies with being able to be the true benefit manager for these health plans, showing them you can say no or re-direct care to a more conservative treatment, that you can evaluate and adjust the diagnosis, take some risk and even be willing to forgo reimbursement. Home health, PT, autism all have opportunities to serve this role, so do DME companies, surgeons and those circling around disease management, such as endocrinologists who work with diabetics, or allergy professionals who are dealing with patients with asthma. I would encourage owners of healthcare businesses to think less about what tactics are more likely but more so how your physicians, therapists, and nurses can turn these tactics into opportunity. My dad certainly did. By the following weekend he was down on our red linoleum floor helping me scrub and giving me a few tips to make it more of a game. He even took me early to see batting practice at a Red Sox game. I bought my own $2 pretzel.