1. 7.7 Million: The number of adults who have co-occurring mental health and substance use disorders according to the National Institute on Drug Abuse. New information on comorbidity from a study done across the globe in Australia. The Queensland Brain Institute released a study this month with Aarhus University showing the risk of developing a second mental health disorder. People within the study who were younger than 20 at the onset of their mental disorder were more at risk than others for developing a second disorder in the next 10-15 years. This study is now the largest and most comprehensive look at comorbidity. The next step for this group is to extend the study to identify the risks between mental disorders and the subsequent onset of general medical conditions, such as epilepsy, migraine, heart attacks, and diabetes. If you are looking for how your practice can get a better deal from insurers in the next 5 years it may be in finding a way to prove how your services can help manage or prevent risks related to this mental health spiral.
2. Marriage of 2 Giants: Anthem is taking a bet that Wal-Mart can help them reduce falls in seniors that can cost thousands in avoidable hospital admissions. Its Medicare Advantage members can get a deal on over the counter household safety items like shower grab bars or elevated toilet seats as well as pain medication and other supplies – up to $330 per quarter for many Anthem MA plans starting this year – incenting their members to go to Walmart (or go online) for these purchases through a new partnership rolling out this month. My mother-in-law, an Anthem member, could use a shower bar now that she’s 80 and forgets to eat and drink enough water, but she won’t shop at Wal-Mart because the last time she was there she got so lost in the Tupperware department that she couldn’t find the exit for 2 hours and missed Saturday afternoon Mass.
3. Oncology Pre Approval For Rx: Medicaid managed care plan Sunshine Health has partnered with an oncology company, New Century, to implement a new pre-approval program for cancer treatment for adults. Starting this month, all oncology-related chemo drugs and support agents will require a preauthorization before administration in a doctor’s office, outpatient hospital or ambulatory setting. Optum, meanwhile, will start requiring pre-approval in February for all outpatient injectable chemo, and related therapies.
4. Hip & Knee Oversight Picks Up: Magellan, starting this month, is now doing pre-authorizations and post-service reviews for Florida Blue’s HMO and PPO Medicare Advantage members potentially needing hip and knee procedures.
5. 17.35: Per member per month savings in managing commercially insured members seen by practices doing value based medicine in Kansas, according to Michael Atwood, MD, who heads medical affairs for Blue Kansas. Atwood said the total PMPM in the value models was $6.50. Getting contracts in the future will essentially require providers to come to the table with a value model, according to 80% in our managed care poll last fall, particularly if they are physicians or practitioners treating patients with chronic conditions.
6. If You Build It, Will They Come? 340B hospitals hope so as more of them in 2019 will roll out their own in-house specialty pharmacy. 26%, in a poll we did, say they have one today, up from just 8% two years ago, and an additional 37% say they will or may build one over the next two years to help capture more prescriptions through the discount program. Yes, there’s been some recent angst about the program given more government attention to it, but in some ways this has forced hospitals to ‘go all in while we can’ given the importance of the program in allowing for ‘community programs to exist and service lines to grow.’ Mercy Health System is building a national in-house specialty pharmacy to be available for all of its patients across its integrated delivery network. 6 in 10 say their SPP is part of the preferred network of most national payers. Health plans are getting into the 340B opportunity – at least a third are trying to create arrangements that incent patients to use the 340B health systems and their clinics and specialty pharmacies. Patients ‘pay less’ by using these discount pharmacies and providers within the closed system.
7. Cardiology The Next Target: Several cardiology procedures will now require pre-approval and post-service medical necessity reviews under a new utilization management program that BCBS of Florida, BCBS of Louisiana and several other plans are starting. Procedures performed in an office or outpatient setting will be impacted, including non-emergency procedures like total knee arthroplasty, knee manipulation under anesthesia, knee ligament repair, hip arthroplasty, echocardiography, diagnostic coronary angiography and arterial ultrasound. The UM company AIM will run the program. Both commercial and Medicare plan patients are impacted.
8. School To Home Mental Health Pilot A Gamechanger? Lutheran Social Services of Wisconsin has hired a therapist and a family coach to work with families of students who are receiving mental health services at two Milwaukee area charter schools. The therapist works with children during the school day, and the family coach makes weekly in-home visits. The model, in my opinion, is likely to be a winner over time and be better positioned with managed Medicaid plans seeking more cost effective solutions to mental health. 14 children and their families are participating in the Wisconsin program; the goal is to expand this to 50 by June, and focus on helping those dealing with PTSD, anxiety, depression and other mental health issues. The group hopes to receive state funding to institute 5 other school-centered pilot programs. It has established a committee consisting of state and county representatives, mental health advocacy groups and community organizations to address local and state policy changes needed to sustain the programs. ‘What we’d like to do is achieve policy change for a more comprehensive model of school-based mental health,’ according to the group’s CEO, Hector Colon. ‘That could include higher Medicaid reimbursements for clinical consultations and in-home family coaching. Dr. Judith McMullen, a law professor at Marquette University and committee member, says getting into the home is key but there are challenges in documenting value, proving how the sessions can elevate overall health. Pascual Rodriguez, principal of one of the school’s involved in the pilot, says he is a firm believer in educating children physically, spiritually and emotionally, but acknowledges limitations on what the school guidance team can and cannot offer to some of the kids, so a program like this fills the gap. The future is integration – and therapy that helps not just the kid, but the family. Question is who will convince the policymakers and payers that their model works. See our story on schools and unmet needs here: PE Circa 1983
9. Extra Point: My eighth-grade daughter has the lead in her school play coming up in March and auditions this spring for the lead in an off-Broadway production of Mama Mia, a regional tour that would start in the fall. She has a good chance at the part and, if she gets it, she’d be doing her freshman year of high school on the road juggling algebraic equations, Catcher in the Rye, and learning Sophie’s lines. Her friends don’t understand why she would want to miss the first part of high school, but artists, musicians, they are cut from a different cloth and, to be honest, their healthcare is the stage. Performing, singing in hallways and backseats, and making up songs on the piano rather than studying for a science test – that’s their script. My Sophie asked me if I could tutor her in math on these road trips with the touring show when ‘mom can’t make it’ and I hesitated – not because I don’t want to spend time with her, but because I don’t know what it means when the math question says ‘Solve for X.’ I mean what kind of question is that?! I will say that if I’ve learned anything from covering healthcare for nearly 25 years now it’s that the secret may be in spending less time doing what is expected and doing more of what just makes us feel good. To heck with high school Soph…break a leg.