83: Portion of parents of teenagers who say they are increasing spending out of pocket and through insurance copays on their own care and health related to stress, anxiety, fitness in part due to recent results of lab work or primary care visits showing some combination of problematic indicators of morbidity, like rising cholesterol, rising BP and hypertension, rising A1c and “less productive workdays.”
Predicting Things: In an old episode of Seinfeld George Costanza once asked Kramer about a discoloring on his lip and Kramer, classically, said “Whoa buddy – better get that checked out,” so George did but his doctor said, “Well I don’t know what that is…I haven’t seen that.” Artificial intelligence seems to be helping where TV doctors and others fall short, particularly when the issue is inside the body. AI used at three UPMC hospitals in Pennsylvania performed better than the most common methods for diagnosing certain heart conditions in patients with chest pain, according to a recent published study. And in another study, researchers found that AI helped predict the development of Parkinson’s disease after analyzing data from over 100,000 smartwatch users. Despite the uptick of AI in healthcare, a recent survey found that 80% of patients still are not comfortable with AI and would prefer seeing actual providers for most healthcare services.
No More Double Dip: Effective October 1, 2023, Horizon BCBS will reduce payment for codes representing problem-oriented E&M services by 50% when the services are rendered on the same date of service and by the same provider as routine/preventive E&M services regardless of which procedure codes are appended with Modifier 25. This comes as little surprise as we’ve seen more and more health plans cracking down on E&M coding, making sure they are only paying for what they deem appropriate. In June, Blue Cross NC said it was halting reimbursement for any imaging services – X-ray, CT, or MRI – when billed within 28 days of a principal diagnosis of uncomplicated lower back pain. The health plan is trying to reduce “excessive tests or procedures that result in unnecessary medical expenses.”
Cell Therapy: BCBS Michigan will begin having providers use a portal to track clinical outcomes for members receiving CAR-T cell therapy drugs in July. Audaire Health will provide the portal and when providers request prior authorization for any of six different cell therapies, they will have to confirm they will enter clinical outcome information as their patient progresses on treatment. The portal is meant to ease administrative burden for providers while helping the health plan track how these very high-cost therapies are actually working for their members.
Vascular Control: Aetna is beginning a new Peripheral Vascular Disease program in September for all commercial and Medicare Advantage members. Services like atherectomies, angioplasties, and stenting will begin requiring preapproval through eviCore.
Look On Bright Side: Molina will buy the remainder of Bright Health’s Medicare Advantage business in California for around $500 million. This means Bright Health will no longer operate at all in the health insurance business and will instead focus on consumer care products.
Policy Switch: Highmark announced this week that they would not reinstate their “Stabilize and Transfer” OON protocol for narrow network products, as had been previously announced. So this means the growing eastern US insurer will continue to pay out of network providers directly when they provide emergency care to members at a hospital or freestanding emergency department.
Extra Point (Partially From The Archives): So my folks were late again to supper last night because they were waiting for each other at the library because it had air conditioning that we don’t, sitting on benches maybe 10 feet apart inside the “Fiction” section, pointed in opposite directions…dad having fallen asleep from one too many cinnamon cookies. I dislike summer, but I love fall. There’s the leaf jumping, apple crisp and college football, the pumpkin seeds, bulky sweaters, and gramma’s mashed potatoes. There’s the Fall guy and the Fall of the Empire, Niagra and Tacko Fall, that 7’6” basketball player. There’s Fall Out Boy, falling in love and Fallen, that great Sara McLachlan song. But would you believe it, some people don’t like fall, even though they keep doing it. Some are just clumsy like me, some like Janice fall because their husbands fail to adjust the bike seat. Others have cataracts or glaucoma or live in the icy north, but many are older folks with dementia or weaker bones or malnourishment or fall from the heat of the summer, for whom falls are as common as Uncle Bobby blaming me again for “deleting the internet” because I removed the shortcut to his browser. My dad has fallen a few dozen times – twice hospitalized – while my mother-in-law fell some 15 times after turning 80 that we know about, most of which have landed her in the hospital. What’s underappreciated about falls – the cause isn’t always what you think. We once studied 65 seniors who had fallen and needed inpatient rehab only to learn that some 39 of them had lost a spouse, never really grieved, and became sedentary. They fell into their spouse’s habits and into a health spiral. So, if you are in healthcare and see seniors or are a caregiver on some level for aging relatives, take note not just of what’s happening inside their body but what’s going on inside their home and their heart.