1. 41: The percentage of parents in our poll who said they are hiring a home health aide for their mom or dad to help prevent another fall. Falls have increased in New England (during the winter months ), largely due to dehydration, lack of a consistent diet, orthostatic/BP issues, and a range of dementia or psych influences, parents said. Of those hiring an aide, 46% said their mom or dad has a Medicare Advantage plan with Humana, United Healthcare, or BCBS, though nearly all (90%) said they aren’t sure what if any of these aide services are covered by insurance. About 85% of those hiring an aide said mom or dad are widowed.
2. Podcast on Capitation: Check out our 30-minute podcast on managed care developments and capitation: Friday Forum
3. Pre-Pay Review Intensifies: 39 of 46 health plans in our poll said they are intensifying pre-payment review policies. Blue Massachusetts, for example, has partnered with Equian to help it improve payment accuracy. The vendor will focus on high dollar claims. Services will be done before payment is sent to physicians, hospitals, and other providers. The actual BCBS pre-pay review process began in April for fully insured accounts and members, while administrative services accounts will be impacted starting in January. Claims will be automatically selected for review based on cost and other factors.
4. Wins and Losses: Starting in January, several medications will not be covered any longer due to recent P&T committee formulary changes. We attended a P&T meeting at BCBS of Massachusetts and found that six drugs won’t be covered including Pradaxa, an anticoagulant for blood-clot prevention; Mirapex for Parkinson’s; Victoza for diabetes; the chemotherapy Neupogen; and several short-term ophthalmic anti-inflammatories (reach out if you’re interested to know which ophthalmic drugs). Several drugs stay on formulary but move to a higher-cost tier, including infliximab drugs for patients with psoriasis or Crohn’s or rheumatoid arthritis like Remicade. Aubagio, an oral drug for multiple sclerosis, and Glyxambi, an oral for diabetes, will move to lower-cost tiers .
5. Extra Point: I’ll report live from the BRG Healthcare Leadership Conference in DC next week, moderating a panel on addiction with leaders from Geisinger, Optum, BCBS of Vermont, and Duke, and debating the future of treatment for opioids. True to form, my kids asked me some really helpful questions about my trip. ‘Dad,’ said Jack, our high schooler who is now looking at colleges, ‘can you ask Duke if they have a good cafeteria? That’s one of the key things I care about in a college.’ I told him he might need to rethink his criteria. My daughter, Sophia, was far more on point: ‘Can you ask them how to solve Tommy’s addiction to watching the YouTube guy playing Fortnight?’ Thank you, Sophie! It’s a fair question and an emerging crisis for many kids, not just my own. Tommy sits too close to the screen, avoids reading to watch this kid play video games, and says he’s got headaches and eyesight issues. This ‘addiction’ to the screen may just be the next big ‘addiction’ crisis after opioids, if you ask me. If you’re in healthcare fields like ophthalmology, optometry, psychology, or primary care, there’s opportunity in this trend. If you are interested and able to attend the event last minute, please email me for information. If you are unable to attend and interested in notes from the session, let me know.