140,000: The number of Tyson Foods employees who will now have their pharmacy benefit managed by PBM Rightway, as the company announced plans to drop Caremark. Rightway says it can guarantee employers savings of 15% on pharmacy benefit costs. Rightway will be one of the first PBMs to work with a Fortune 100 company.
Unlimited Labs: As of January 15, Cigna removed annual limits for presumptive and definitive drug testing.
Pre-Natal Nonsense: In interviews with a handful of Medicaid MCOs, each said they continue to struggle to find ways to get newly pregnant beneficiaries to use an OBGYN for the initial ultrasound and pre-natal care, as most just "go to the hospital" instead. The patients, like Than Soe and his girlfriend, say it's a two-way street, as they couldn't find OBGYNs in their area of the state who had openings. Soe said his sister went just one time to the hospital after her pregnancy, and the next time seeing a doctor was at labor. "My nephew is 4 now and not speaking - I'm not sure if that would be different if we had a doctor earlier."
DACON Artist: Pharmacies have a system to measure when patients fill their scripts too early or too late, known as daily average consumption or DACON, but is it underutilized? At an informal straw poll at the local pharmacy this week, 4 of 9 patients told us they were late refilling the script, as much 1-2 weeks, mostly because they "missed some days." But the pharmacy assistant said the system does not send a flag to the patient's doctor. "They won't know - unless you tell them," the teller said. Managing care can be more art than science, but when evidence of poor adherence like this is clear, shouldn't the system find ways to share that intel?
Teeth Grind: Several dental insurers have told us they've seen a significant increase in the number of occlusal night guards delivered to adult patients and an increase in crowns in patients 65 years and older - trends indicating an increase in stress-related bruxing or teeth grinding, which may also have led to an increase in cracked or fractured teeth in seniors, sources said. One insurer, Delta, has recently partnered with the American Heart Association to implement a new standard of care for heart health screening at dentists’ offices via blood pressure screening and primary care referrals.
Pain Delay: On January 1, a BCBS of Massachusetts policy that limited coverage of monitored anesthesia for certain colonoscopies and other endoscopy procedures went into effect, as we reported last month. Following backlash from the provider and patient advocate community, they announced last week that they are postponing this policy change indefinitely.
Disparity Data: The newest healthcare acronym is SOGIE, which stands for sexual orientation and gender identity and expression, and some providers are pushing for this to become a standard part of data collection. Marginalized populations like those who identify as LGBTQ+ often experience health disparities, but the extent of those is likely unknown because this data isn’t consistently captured.
Stay Home: Priority Health, the Medicaid plan in Michigan, recently began reimbursing urgent care centers for services provided virtually. Prior to January 1, urgent care centers were excluded from the plan’s telemedicine policy.
Gonorrhea Precursor: Gonorrhea cases rose by 28% between 2017 and 2021 and if left untreated can lead to long-term health problems, including pelvic inflammatory disease and infertility. If only the health system consulted Kramer, who made it look easy to diagnose Gonorrhea back on Seinfeld when he compared his ‘burning pain’ to the haunting memories of lost love. Diagnostics may get easier now that the FDA has approved the first commercial at-home test for sexually transmitted diseases. The kit, called Simple 2, is made by LetsGetChecked and currently costs $99, but following FDA approval, could gain commercial coverage.
Pre-Authorization: New Jersey has signed a comprehensive prior authorization bill into law that lays out mandated turnaround times, public reporting of some metrics including the number of denials and their reason, and which physician is permitted to deny a request. Another key element of the bill is that if a patient receives a prior authorization from a former health plan, the new health plan must cover the treatment for at least 60 days until a new approval is processed. Other states, along with CMS, have also been active in enacting prior authorization related legislation. Look for our report on developments in this space later this month.
Extra Point: Amara Ojo grew up in Nigeria catching dinner by plugging an empty water bottle over a cricket hole at dusk and playing marbles on a bumpy dirt bamboo floor in her one room home until it was time to sleep - she couldn't have known life in the US would be harder. Amara is a home health aide here in the southeastern part of Connecticut, makes about $20-25 an hour helping older folks mostly. She has largely been out of work over the last week after bringing her 9-year-old daughter Jasmin to the hospital last Friday for "the asthma," at least that's how Amara describes it. She had been waiting for approval for a medication at the pharmacy because the state wouldn't cover the prescribed brand. The asthma got worse while she waited and so Amara picked up her 4th grader, headed to her red Hyundai and drove four miles to that hospital. The pediatrician who was still trying to get the treatment approved says her practice spent more than 30 hours on calls with pharmacies and insurance companies last week alone, trying to adjust medications and get authorization. The practice estimates that it costs them about $144,000 a year in time dealing with these requests, and it's part of the reason they hired another office manager to assist. Jasmin was discharged this morning - a bit weak, but stable and ready to be home. Her hospital visit unofficially cost about $24,000. Amara missed 4 days of unpaid work this past week, lowering her $600 weekly income to less than $250. "I was very worried about some of the families who need me - they can barely stand without falling," she said. She took Jasmin for a root beer float on the way home that would have cost $5.00 but the waitress spotted Jasmin's hospital ID bracelet. "She said, 'it's on us'." All told, Jasmin missed 5 days of math and 3 days of her favorite subject, science, plus a dance recital and her grandma's birthday. Amara told me parts of her misses the predictability of her time in Nigeria. "There was violence, and we were scared most nights - marbles were a distraction," she remembers. It was in some ways a simpler time but "I wouldn't trade my time here in America - I do it for her."
Editor: Ashley Chilton; Contributors: Samantha Kaishian, Hannah Landi; Extra Point: Bryan Cote