5.4: The amount employers expect health benefit costs per employee to rise in 2024, largely due to market wide factors like inflation and labor shortages, along with healthcare specific costs like the approval of more gene and cellular therapies and increased utilization of the GLP-1 drugs for weight loss. This projected increase is larger than what employers have seen year over year in the past, which means self-insured employers will likely put additional pressure on health plans to try to keep costs down. “Expect continued emphasis on preventive measures, using telehealth to guide employees to the right services,” says Max Valencia, an HR manager. “At one company we are raising copays quite a bit for the services that get used a lot but aren’t always necessary, like urgent care.”
No More Pre-Approval: BCBS Minnesota will no longer require prior authorization for any commercial members who need skilled nursing visits. And in Michigan, BCBS announced they will remove 20% of PAs for procedures like bariatric surgery, breast biopsy, and cardiac rehab services across both Medicare and commercial members. BCBS will also amp up its gold card program where physicians can be excluded from needing to seek prior authorization based on past approval rates.
Hold On: Not all insurers are taking off the controls. Florida Blue joins a growing number that will more aggressively manage cardiology services. They will use Evolent Health for its Medicare Advantage members.
Changing Partners: In December 2023, Highmark Blue is moving from third party benefit manager Tivity to Helion Arc to manage outpatient physical therapy services. The announcement notes that qualifying providers may still receive up to 20 auto-approved visits per member, likely in some form of a gold card program.
Finding Specialists: One of the biggest challenges for consumers is getting to the right specialist at the right time – in our poll of 1,600 adults, 67% said after referral to a cardiologist the earliest appointment was 7-9 months out, “which is not a great system – you don’t see that kind of a wait for cancer,” lamented 53 year-old Shirley Feeley, whose high calcium scores were troubling to her internist given family history. Anthem is offering Medicare Advantage members a new way to search for specialists called Personalized Match Phase 1. When members access the Find Care tool online, providers will be listed or ranked by their quality and cost scores relative to their peers in the member’s preferred mileage search radius. Patients will be able to sort provider results in other ways, but the default will be based on providers’ scores, though the actual scores won’t be visible to patients.
Retailer Spread: Walmart is reportedly in talks to purchase primary care practice ChenMed. If the deal goes through, Walmart will be the latest retailer to move into the primary care delivery space, following similar purchases by Amazon, CVS and Walgreens. And speaking of Walgreens, they announced a new partnership with Pearl Health, which has a platform to help enable value-based care. The platform will be used in Walgreens’ relationships with community-based primary care physicians.
AI Tool: Microsoft and Paige, a pathology AI company, are developing a new generative AI model focused on cancer diagnosis. Paige will use up to 4 million digitalized microscopy slides to develop new clinical applications and biomarkers with the goal of deploying them in hospitals and labs.
Check It Out: GoodRx launched a new feature that allows providers to check a patient's insurance benefits when prescribing medications to better understand the final cost. The real-time benefit check is available in GoodRx's "Provider Mode," which offers providers a dashboard with drug cost comparison tools and other resources for patients.
345: The number of moms and dads we polled about a seemingly mundane question – how they decide where to go for healthcare. Moms seem more thoughtful – relying on their OBGYN or their neighbor who’s a pediatrician, or NPR, while Dads, somewhat predictably, rely on ‘it getting better without them doing anything” said some, or, increasingly, the nearest urgent care. Moms are more often changing doctors and more thoughtful about where to go and whose advice to use. Unlike Elaine of Seinfeld fame who failed to change doctors because her last one wrote in her medical record that she was too difficult, today’s generation of Elaines have more access and control over their records, and more say in where to go. They tend to rely more on what they know, hear and see every day, sometimes for good and sometimes not. In our study of 345 adult consumers there are some clues as to how people select specialists and how little people rely on insurance to guide them.
Extra Point: Something seems lost in translation these days around helping people in crisis. Just 13 states and DC by my count provide reimbursement for the cost of medical interpreters through Medicaid and states that don’t say that the cost is part of existing reimbursement, like to a hospital. But there is a growing need for interpreters – in a survey we did of 550 hospitals about 35% don’t offer them at all and another 40% said they have had trouble staffing the function, partly due to the rising demand, the influx of the refugee population in the US, and the lack of reimbursement. Our oldest daughter does interpretation and says one of the underappreciated issues is interpreters sometimes cut corners. “I’ve seen so many interpreters not doing their jobs properly…especially not interpreting everything that the doctors and nurses say to them. It’s just not accurate most of the times.” Kyoe, 23, who grew up in a refugee camp in Myanmar learned Thai other languages as a kid, says she has had to hold back many times when listening to interpreters who are interpreting for her family members and friends. “I feel like hospitals and schools should allow third parties to interpret - it’s not fair on elderly folks who don’t understand English have someone to interpret for them who they don’t understand and who doesn’t know them.” Maggie Fleeter, an ER nurse, says she feels like it’s a big gap in the discharge process – definitely for seniors and for people with mental health conditions. “We see a lot of back here because something was lost in translation. I think we can do better for these patients.”