740,000: Number of New Yorkers with medical debt on their credit reports as of February 2022 – that's 6% of all residents in the Empire state. A report by the Urban Institute found that NY communities with the highest prevalence of medical debt also faced additional challenges in accessing healthcare – high-debt communities were more rural, had higher rates of disability, and had lower rates of employment. A bill that passed New York State Legislature last month and is awaiting the governor’s review would prevent all medical debt from being included in credit reports.
AI Making Care Decisions: No the great 76ers point guard Allen Iverson is not the new medical director of healthcare but like the hall of famer’s agility navigating to the goal or passing the ball, healthcare’s “AI” is taking on the role of traffic cop under a pilot program from HCSC, the parent company of Blues plans in five states. The AI pre-authorization tool doesn’t deny any requests - it will kick it over to a clinician if it feels it doesn’t have enough info to approve. During the initial pilot in 2022 for specialty pharmacy and behavioral health, approvals were granted 80% of the time for behavioral health and 66% for pharmacy, and the health plan said it streamlined the process substantially. Now requests for a variety of services will utilize the tool, including inpatient, long-term care, home health, hospice and outpatient services.
Alzheimer’s Cost: The FDA recently decided to grant approval Leqembi, which marks the first time in two decades that a drug for Alzheimer's has received full approval. Clinical trials suggest that Leqembi, administered by IV infusions every two weeks, can slow decline for people with mild symptoms by five to eighteen months. The approval means that Medicare will cover Leqembi for eligible patients at 80% of the total $26,500 cost, leaving patients responsible for the remaining thousands of dollars in co-pays. Medicare Advantage plans will now have to decide if and how they want to cover the drug. Commercial plans will cover the drug with pre-approval and do a review of the site of the infusion, trying to push it to outpatient. The additional cost could lead to increased premiums for all beneficiaries, not just those taking the drug.
Good Drug Combo: CVS Caremark, the PBM, will offer its members access to GoodRx’s prescription program starting next year. The partnership, known as Caremark Cost Saver, will allow members to still use their pharmacy benefit while accessing GoodRx’s often cheaper drugs. The amount members pay will apply against their deductible.
Senior Clinics: Novant Health, the North Carolina based health system, is partnering with Ochsner health to build “65 Plus” health clinics across the Southeast, providing more access to medical services along with social events and health coaching to seniors. Meanwhile, Virginia Mason Franciscan Health has become the new main acute care referral partner for UnitedHealth’s Optum Washington polyclinic. There’s no financial component according to Virginia Mason’s CEO, but all patients at this Optum clinic will now be referred to Virginia Mason Medical Center and Optum will help manage the health system’s Medicare Advantage patients.
COPD Is Latest To Go Digital: Highmark BCBS recently added virtual COPD treatment provider Wellinks to its network, which will provide 500,000 members in Delaware with access to virtual pulmonary rehab services like exercises, education and personalized coaching.
Bed Less: Health systems are trying to keep up with behavioral health demand by opening new centers. Geisinger opened a new 96-bed unit in Northeast Pennsylvania, in partnership with Acadia, which will begin taking patients August 1. And in Ohio, Akron Children’s Hospital went the outpatient route, hoping to divert pediatric patients from taking up mental health beds in ERs. Patients will have the choice of an all-day program that runs for ten days or an after-school program for three days a week.
Extra Point: Sometimes credit is misplaced, like my bride gave me credit for fixing the toilet leak when it just self-resolved because if I ignore something long enough sometimes I get lucky. Or like in healthcare these days there are a lot of people complaining that they should get the credit for having lowered the patient’s health risk - a social service company tried to persuade a Medicaid plan that their 5 weekly visits to a community of refugees in Minnesota had a much greater impact on the 60% decline in so-called avoidable ER visits than any of the doctors who work inside a building. “We basically helped these people understand that many times their symptoms could self-resolve or be fixed with changes at home, but we weren’t getting the bonus the doctors were getting,” Paula Kreeger said. A primary care group in the south used its data to convince a Medicare Advantage plan that 261 patients it treated in 2022 should be “attributed” lives, based on a detailed history of when they met the patient, A1C scores for diabetes at the point of care, the treatment plan notes, follow up call log, and follow up visit. “We asked the health plan to show us if these patients had seen another provider that could have indirectly impacted their health too – but they only could come up with that on 18 of them,” Molly Plant, a care coordination director says. Mark Swayne, an attribution specialist, admits that they are encountering attribution issues now with all the bundles and separate contracts with groups managing the same population – “it’s gotten messy assigning who gets credit for cost savings.” My mom used to say not to worry about getting credit – “you can like it or lump it” she’d say. I didn’t really know what she meant until 6th grade when Miss Rosebrooks blamed me for killing the goldfish by dumping too much food in the bowl. I was maybe 25% responsible since I was holding the food, but Lenny pushed Charlie who bumped into me, so her blame was misplaced. But at 12 years old I had a metal Star Wars lunchbox, could ride my Huffy dirt bike to school and wore blue polyester bell bottoms 4 days a week, so I had it pretty good, obviously. And so sometimes you just need to take your lumps, keep your chin up and be thankful for just being.