1. 181%: Rise in total ER costs in the last few years according to a Blue Texas study of its membership. The increase correlates in part to the rise in freestanding ERs in this state. Blue TX is taking on more of an effort to do claims reviews to manage claims – described to us as a soup to nuts review for HMO patients using OON ERs. The plan is going to be ‘holding the claim requesting medical records, checking the bill to make sure that’s what happened in ER matches the record, and combing the record to assess patient history and whether the patient’s decision to go to the ER was what a ‘prudent layperson’ would do; in other words, was it reasonable based on history and symptoms. There was one case, in Atlanta, where a 55-year old Male last month said he was confused and worried about the cost of health care and ‘had seen a newspaper story about ER coverage’ so he didn’t go to the ER for what he described as itchy scalp. Joe, a tire salesman, eventually went to urgent care which his daughter Frailey says ‘missed what was happening and just sent him home with a cream.’ He was about to have a stroke and was hospitalized 2 days later. These insurers are not denying off the bat and don’t want patients to avoid the ER. There is no secret list of codes as some news stories have reported; the insurers are trying to find evidence to support the prudent layperson argument and have a physician only review the records to make that decision. In some cases, they can save the patient money. Blue TX says there are occasionally times when there’s ‘a CAT scan’ for example billed but the record shows the patient got penicillin and a throat swab for a sore throat, so by finding this before the patient is balanced billed the insurer saves the patient a high bill due to their coinsurance.
2. Free Ride Halted: This BCBS Blue Card benefit has been useful tool for patients to access specialists and doctors out of the state, not just emergency care if on vacation, but starting in January Blue Shield of California wants to reign in who can go where. California PPO and HMO individual and family plan members will still have access to the BlueCard Program but they will have to get pre approval first if going out of state unless it’s for an emergency or urgent care. ‘It may be hard to get Blue Shield to authorize health care services for an out-of-state provider unless there’s an access issue’
3. I-Man: I may need giant spectacles like Jerry Seinfeld once used in an episode where he and Lloyd Braun were on a search for gum….I blame the iPhone and my affinity for writing. If many of us keep up using technology at such a pace, the shortage of ophthalmologists may become a bigger deal. There are 19,216. ophthalmologists in the United States today, according to the American Academy of Ophthalmology, but it is estimated that approximately 450 new ophthalmology residents graduate every year and 550 established ophthalmologists will retire. This coupled with the aging of the population and there’s a worsening shortage unfolding. The Academy says that many ophthalmologists are seeing a dissatisfaction with decreasing reimbursement trends, which makes it difficult to regenerate early investments of costly technology of starting up a practice.
4. Guard Up: Anthem’s MA plans have been promoting Colorguard in mailers to patients as an alternative for colonoscopy. A Columbus area couple, both with an Anthem MA plan, showed me a letter they received with suggestions on how Cologuard works and why it would beneficial for them. They both are due for their colonoscopy soon
5. Home Care Middle Man: MyNexus, a home care benefit manager, has won the role of delegated utilization management for Anthem Medicare Advantage. The question for home care providers is can they offer an alternative to UM firms by taking on the risk of chronically ill seniors, keeping them out of the hospital for a PMPM that saves the health plan money, reduces family and patient stress and effectively cuts out the middleman in healthcare. ‘I think the best model is having a nurse and therapy team who can be on the front lines with the patient, doing remote monitoring, helping make sure patients are hydrated and safe and paid to help them manage all of things going on – dementia, depression, heart disease, maybe diabetes. ‘It’s hard,’ says Springfield IL based home health business co-owner Norman Hughes: ‘these intermediaries are trying to make a difference but it seems they are more so just adding cost and getting in the way….I would think a better model is just paying us to take on the risk of keeping patients at home’
6. Predicting Admissions: Availity has had success getting insurers to use its cancer treatment profiling technology, a predictive analytics model with a report scoring chemotherapy patients by practice showing their risk for a potentially avoidable admission. The weekly report uses many variables to determine a patient’s risk.
7. Psych Testing Monitoring: 9 In our poll of 11 benefit manager directors this week, 9 out of 11 say they are relaxing requirements around routine psychological and neuropsychological testing. All 9, including Blue TX, say they no longer will require a pre approval for such tests and only would start to change this if ‘a provider’s pattern of testing varies significantly from their provider peer group.’
8. Imaging Check: Starting in December, National Imaging Associations and Magellan will start doing clinical validation of records as part of a new process for codes that are part of the advanced imaging series. This will be done for Blue Florida, as well as other plans for which Magellan/NIA are contracted. The validation takes place during the PA process; they basically ask the ordering provider for more information to justify the request.
9. PMPM Swing: Blue Kansas says it is saving $17 per member per month via its commercial value based programs, with cost of care about $6.50 less on a PMPM basis chronics in these programs vs. those who aren’t.
10. In case you missed it: A health plan in the east has created an episodic payment model for those treating Crohn’s disease. Payment includes behavioral health treatment for those with depression or anxiety stemming from the disease. 50 patients were involved in the initial pilot at the Digestive Healthcare Center in New Jersey. The payer, Horizon Blue, pays them a fee for service, then shares savings with the group after a year of service based on the group’s quality metrics performance. If I’m reading this, part of the story here is not just about how to pay and incent good care but it’s a roadmap for the group practices of the future – those who can integrate the right specialists and services to manage the cost ‘in the clinic’ setting rather than rely on others. In a quick poll of GI doctors, 31 of 43 said they would or have entertained the idea of bringing in a therapist as part of the practice offering to help patients deal with the mental health effects of their conditions. This model, and the inclusion of behavioral treatment in the episode, is somewhat similar to Horizon’s payment structure for maternity and post-partum
11. Extra Point: My 15-year-old son Jack wants to be a physical therapist so he was looking up colleges and found this cool website. ‘What’s it called?’ I asked. ‘Nike I think – it’s really cool, lists all the colleges with PT programs.’ I asked Jack to spell it. ‘N-I-C-H-E’. ‘Um, kido, I think you have a bigger problem than which school to go to.’ After we got through a quick spelling and vocab lesson, I helped Jack deal with some teen angst over choosing colleges and careers. He’s really interested in sports broadcast journalism, and in PT. ‘Why choose? Certainly not now,’ I said. ‘And look, who says you can’t broadcast the hoops game from the sideline and then during the injury timeout put the microphone down and go be the trainer, assess the need for one of those boots, braces or casts…you could call yourself the ‘Cast Man’.’ He looked at me like I had no idea what I was talking about…but if you ask me, it’s not a half bad idea.
Managed Care Friday Forum: Today, Nov. 16th, 11am, 800-874-4559 (Passcode: COTE37301). Recording will be made available.