1. 1,504. The number of children under age 17 admitted into hospitals for opioid overdoses from 2012 and 2015, up from 797 from 2004-07. Researchers at the Comer Children Hospital in Chicago determined these underage overdoses occurred from children getting their parents prescription medication, and particularly children under six years of age who were consuming methadone, a treatment for opioid withdrawal symptoms.
2. Rocky MLR: When meeting quality outcomes targets, 26 physician practices in Colorado earned a share in savings from the Rocky Mountain Health Plan during a recent Medicaid pilot – a 2% adjustment was made to the Medical Loss Ratio for each target the physicians met. Targets largely focused on obesity, diabetes, and depression, including HbA1c poor control greater than 9% (target=28%), adult body mass index assessments (target=82%) and proof of effective acute phase anti-depressant medication management (target=56%). Payments were distributed based on patient volume and risk scores, 60% to primary care physicians, 30% to community mental health practitioners and the rest to the health plan. There was about $5 million saved by 28 practices representing about three quarters of the 35,000 Medicaid population in the program.
3. Pain Response: At Colorado Medicaid’s recent meeting there was some discussion about NSAIDs and whether injectable ketorolac (for pain) has a lot of use in the Medicaid population – a report will be run and discussed at the next meeting. Additionally, the board will allow Narcan nasal spray to be prescribed without prior authorization ‘in the near future’, according to Cathy Traugott, RPh.
4. Network Mix: Just to give you a sense of a health plan’s network size, in New Mexico, there are just 4,222 primary care physicians in the Blue network, though this is about twice the number in the plan’s Medicaid network and nearly 3x the number of PCPs in their Medicare Advantage HMO. In all, BCBS here has 33,568 participating providers, made up of nearly 10,000 allied health practitioners (like PTs, podiatrists, optometrists) and 6,600 behavioral health practitioners in the network.
5. Out of Network, Out of Favor: Several upper Atlantic health plans have essentially halted out of network substance abuse treatment for members who fly to Florida, but in one plan – Horizon – is extending treatment for those who use providers in the area, moving toward ‘full year episodes’ that feature peer recovery and incentives to ‘engage’ the patient through transitions, says Mary Ann Christopher, RN, Horizon’s chief of clinical transformation.
6. Opioid Entrée To Marijuana Program: Opioid withdrawal can soon be considered one of the conditions a patient can claim when applying to be part of Connecticut’s medical marijuana program. Four other conditions were discussed being added including albinism, osteogenesis imperfecta and progressive degenerative disc disease of the spine at a state Board of Physician meeting this past week. At a federal level, marijuana still remains as a controlled substance. There are currently 22 conditions that qualify adults and six for children for the Connecticut state medical marijuana program.
7. Three’s Company? A surprising 61% of physicians in our poll of 274 of them yesterday think the most recent proposed merger (Express, Cigna, and medical benefit manager Evicore) isn’t anti-consumer or anti-provider, but pro-outcomes. ‘Getting approval for a script now comes with a lot more data behind that decision – or it should. We are moving into having to justify everything and get paid for better monitoring of patients and better outcomes but we don’t have the data usually. It’s not just Cigna saying yes or no or the PBM using a step edit or fail first policy or prior authorization, it’s the data from the medical side about prior procedures and history,’ says Gary Rantel, MD, an internist. ‘It’s a more complete picture of the patient before a green light…for me, I lack an understanding of what happens to my patients in between visits. Maybe this helps’
8. Generic Limit:: Alabama Medicaid will create a new process to limit simultaneous use of drugs containing at least one identical generic chemical, initially focused on gabapentin and pregaballin drugs. A review of 2016 claims found 770 patients on at least two strengths of gabapentin. Medical justification will be needed for patients to be on 2 strengths of the same medication at the same time. Other drugs may be added.
9. Cell Transplants: UnitedHealth Group updated their coverage review requirement for commercial, Medicare Advantage and Medicaid plan members to add chimeric antigen receptor T-cell (CAR-T) therapy, including tisagenlecleucel (Kymriah™) and axicabtagene ciloleucel (Yescarta™). CAR-T therapy is a form of adoptive cell transfer that’s shown promise in the treatment of certain hematologic malignancies.
10. Hospice, The Cardinal Way: Kindred Healthcare has collaborated with the University of Louisville to create health care technology solutions, including apps, that may improve the lives of the aging population. One app would assess a patient’s eligibility for hospice care. The partnership, called ‘HIVE’, brings Kindred employees together with Cardinal students to develop apps and other elderly-focused projects.
11. Two Hours: There’s a lot I used to be able to accomplish in 2 hours, that before I had children. Health plans, for their part, have their own time constraints given the drain of the pre-approval process. For example, in Alabama, there were 25,881 prior authorization requests this time last year (in January) filed electronically with the state’s Medicaid office, with just 10,505 manual. These numbers stayed relatively flat through the first quarter last year and, on average, manual PA requests were completed usually within 2-4 hours.
12. Boston 150: Sixteen Blue plans have told us that they have already or will move in the direction of changing out of network provider claims reimbursement for PPO plans to reduce exposure to OON charges. Many say they looked at Blue Massachusettts’ policy as a starting point in discussions. Blue MA sets the OON rate at 150% of Medicare, while several other Blues say they may go lower (e.g. to 130%)
13. Extra Point: My daughter Sophia sang her little heart out this week in a rehearsal for her middle school’s performance of Legally Blonde. She is playing this character who jumpropes her way through the song. I can barely drive and text at the same time, so I have to say I’m really impressed with Soph’s ability to multi-task. Of all our kids, she’s my favorite on most days, and she never surprises – at breakfast, while waiting for the waffles to pop the other day, she said she wanted to be a doctor. She’s apparently on the right side of the trend as there are now for the first time more women than men in medical school. “I think it's great that women are now attending medical school in record numbers,” says Laura Erickson-Schroth, MD. “This means that women have access to fulfilling careers and patients are receiving care from a more diverse group of doctors.” The development is small but meaningful for many of you with practices looking carefully about how to find, use, and retain good physicians. They are out there. Perhaps one place to look is on a middle school stage, Act 2. Look for the girl with the pony tail and the sweet voice. Click here to read the full piece.