10%: The amount of all physicians in the US who are now employed or affiliated with UnitedHealth, according to the healthcare group’s investor day this week. That equals roughly 90,000 doctors who are part of the behemoth that includes a health plan, a PBM, a specialty pharmacy, and more.
Drug Authorizations: Highmark BCBS will begin requiring prior authorization for 60 high-cost drugs in January 2024 for their Federal Employee Program (FEP) members. The change will move the medical necessity review from post-service to a pre-service review. And starting in January, BCBS Tennessee will no longer use MagellanRx for specialty drug prior authorizations and instead will manage the process internally.
Cleveland Rocks: Cleveland Clinic and Canon are partnering to build a research imaging center based in the Cleveland Innovation District. The center will focus on cardiology, neurology and musculoskeletal medicine and aims to improve patient outcomes, diagnosis and care.
Dad Days: New research from the University of Southern California shows that paternity leave can pay a “lifelong dividend” for fathers. Researchers compared first time fathers in Spain to those in California and found that fathers who spent more one-on-one time with newborns experienced changes in the brain associated with sustained attention. The US is an outlier when it comes to paternity leave with paid family leave laws having been enacted in only 14 states as of September.
Where Is VBC Working? Value-based arrangements made the biggest difference in outcomes for osteoporosis, breast and colorectal cancer screening, and eye exams in diabetes care, according to Humana’s 10th annual value-based care report that compares outcomes among their members who are in some type of VBA versus those who only receive care through fee-for-service arrangements. 70% of Humana’s MA members are aligned to VBA providers, the highest Humana has seen since tracking this metric. And in good news for providers, VBA physicians earned, on average, 3.4x the Medicare fee schedule.
Cost Based Pricing: Express Scripts is launching a new pharmacy network option, ClearNetwork, which will offer cost-based pricing. ESI will rely on the lowest of three published benchmarks—National Average Drug Acquisition Cost, Wholesale Acquisition Cost, or Predictive Acquisition Cost. Pharmacies will receive a flat dispensing fee along with an unspecified portion of a fee that will be "up to 15%" of one of the above three benchmarks. ESI says this option will be “straight forward” but it’s still not clear how much savings this could result in for employer clients.
Saliva Screen: George’s fiancée, Susan, has made us all think twice about licking the envelope this time of year, victimized by her own saliva and a toxic adhesive in the classic Seinfeld scene. Saliva tests for drug addiction are much safer than Costanza’s envelopes, but are they accurate? Several insurers say there are a high number of false positive results with these tests, particularly in smokers. These tests are likely to be scrutinized more in the coming years by insurers as they attempt to help in drug detection but do so affordably. Saliva tests can help with detecting very recent abuse, but they only detect abuse for a few days. These tests can also be used to help diagnose Autism in children.
Referral In The Way? Two years ago we reported that 59% of 25-35 year olds in our consumer poll said when the times comes they will “likely” or “definitely” choose Cologuard’s at home screening test for colon cancer over colonoscopy, several citing advantages like “not having to do the prep my dad did” or not “having to be sedated” and even financial benefits for those who say they may just pay cash “and I think the at home is a lot cheaper.” If a Cologuard test is positive, the patient will need a colonoscopy, but only 39% knew this. However, the cost of the colonoscopy in this situation would be applied to the patient’s deductible if they are using insurance. 20% said they would “definitely” choose the test, 39% “likely.” In our recent poll of the same audience two years later, the results are directionally similar but there’s a new wrinkle – several said their parents have had to pay full cost for the colonoscopy – or fight the cost - because they didn’t get a referral from their primary care doctor. In several cases, the insurer sent a mailer to 45–55-year-olds encouraging them to get a colonoscopy with one of 2 doctors in the insurer’s network – they provided the phone numbers and websites – and said the screen would save lives. But these adult parents still got a bill for $800 or more.
Teen Talk: Virtual behavioral health company Talkspace will provide free services to more than 400,000 New York City teens through a partnership with the NYC Department of Health and Mental Hygiene. The partnership will launch a new program called TeenSpace through which 13- to 17-year-olds can connect with licensed therapists for free over the phone or through text.
Extra Point: My cardiologist and my dog’s vet were equally frustrated this week over our lack of sustained exercise and recent dietary decisions – mine leading to elevated calcium scores, Zaggy’s to what seems to be a combo of sleep apnea and GERD. Who knew dogs could get those? So we both turned on Rocky’s Gonna Fly Now this week in search of renewing movement – Zaggy chased squirrels, I found my way to Orange Theory after a 4-year hiatus from the hit gym class that measures performance in so-called “splat points,” the theory being that putting each person’s points up on a public TV monitor is a way to push people to be their best. I have a theory that it makes me nauseous. In my first week, for some reason, I had zero splat points in both my visits—the lowest in the class, 40 worse than my bride and 50 worse than my daughter leading me to believe that managing my own care is exhausting, humiliating and undoubtedly hurting my status in the family. The hit gym classes aren’t just winning with families, millennials and 30 and 40 somethings, they are getting the attention of self-insured employers and a few large payers too. I asked a half dozen benefits administrators for leading employers with more than 15,000 employees – and all but one are looking at developing a contract and perhaps a pilot program to measure productivity and wellness for employees and several mentioned the popular Orange Theory as a possible partner. The theory is that the class meets you where you’re at, improves strength and conditioning and, according to one analysis, reduces prescription spending, absenteeism and A1c scores. Some said these pseudo gym classes likely have better long-term results compared to the GLP-1 weight loss drugs. We will have to see. I’m just hopeful splat points won’t be a measure companies or insurers use to set premiums and benefits, at least not until I figure out how to do more than 3 burpees without needing to “take five” in the corner.